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A  TEXT-BOOK   OF 
OBSTETRICS 


BY 


ADAM    H.  WRIGHT 

PROFESSOR    OF   OBSTKTRICS,    UNIVERSITY  OF  TORONTO 

OBSTETRICIAN    AND    GYN.«COLOGIST    TO    THE 

GENERAL    HOSPITAL,  TORONTO,  CANADA 


IVITR  TWO  HUNDRED  AND   TWENTY- 
FOUR   ILLUSTRATIONS    IN    THE    TEXT 


NEW    YORK    AND    LONDON 
D.    APPLETON    AND    COMPANY,    PUBLISHERS 

1908 


Copyright,  1905,  by 
D.  APPLETON  AND  COMPANY 


PRINTED  AT  THE  APPLETON  PRESS 
NEW  YORK,  U.  S.  A. 


A  TEXT-BOOK    OF 
OBSTETRICS 


BY 


ADAM    H.  WRIGHT 

PROFESSOR    OF   OBSTETRICS,    UNIVERSITY   OF   TORONTO 

OBSTETRICIAN    AND    GYN.ECOLOGIST    TO    THE 

GENERAL   HOSPITAL,  TORONTO,  CANADA 


WITH  TWO  HUNDRED  AND   TWENTY- 
FOUR    ILLUSTRATIONS    IN    THE    TEXT 


NEW    YORK    AND    LONDON 
D.   APPLETON   AND   COMPANY,   Publishers 

190^ 


Copyright,  1905,  by 
D.  APPLETON  AND  COMPANY 


PRINTED  AT  THE  APPLETON  PRESS 
NEW  YORK,   U.    S.    A. 


e 

-J 
a 


S3 


TO 

WILLIAM     OSLER 

KEGIUS    PROFESSOR    OF    MEDICINE    AT    OXFORD 

PROFESSOR    OF    MEDICINE,    JOHNS    HOPKINS    UNIVERSITY 

BALTIMORE 

A    GOOD     PHYSICIAN" 
A    KIND    FRIEND 


"There  are  many  speculations  in  Literature,  Philosopliy,  and  Re- 
ligion, which,  though  pleasant  to  walk  in,  and  lying  under  the  shadow 
of  great  names,  yet  lead  to  no  important  result.  They  resemble  rather 
those  roads  in  the  Western  forests  of  my  native  land,  which,  though 
broad  and  pleasant  at  first,  and  lying  beneath  the  shadow  of  the  great 
branches,  finally  dwindle  to  a  squirrel  track,  and  run  up  a  tree." 

—Longfellow,  Hyperion. 

"I  am  not  only  ashamed,  but  heartily  sorry,  that,  besides  death, 
there  are  diseases  incurable  :  yet  not  for  my  own  sake,  or  that  they  be 
beyond  my  Art,  but  for  the  general  cause  and  sake  of  humanity,  whose 
common  cause  I  apprehend  as  my  own. ' ' 

— Browne,  Religio  Medici. 


PREFACE 


This  book  has  been  published  at  the  request  of  students  and 
fellow  practitioners.  An  intimate  association  with  students  and 
physicians  and  a  careful  stud}^  of  their  wants  have  convinced 
me  that  a  work  on  Obstetrics  should  be  practical  in  the  broadest 
sense  of  the  word. 

I  recognize  the  fact  that  students  have  learned  anatomy  and 
physiology  before  they  commence  the  study  of  obstetrics,  and  I 
have  therefore  given  only  a  summary  of  facts  anatomical  and 
physiological  which  are  important  from  an  obstetrical  stand- 
point. While  the  brief  chapters  on  anatomy  and  physiology  are 
intended  especially  for  students,  the  main  portion  has  been  written 
for  both  students  and  physicians. 

In  my  endeavors  to  be  practical  I  have  adopted  chiefly  clin- 
ical methods.  I  desired  to  avoid  the  "lecture  style"  in  writing; 
but  I  have  to  acknowledge  that  my  dogmatic  manners  as  a  teacher, 
and  a  considerable  amount  of  egoism,  are  evident  in  many  parts. 
As  an  excuse  for  this,  I  shall  follow  Herman  in  quoting  the  words 
of  Bacon :  "  The  manner  of  the  tradition  and  delivery  of  knowl- 
edge which  is  for  the  most  part  magistral  and  peremptory  .  .  . 
in  a  sort  as  may  be  soonest  believed  and  not  easiliest  examined 
...  in  compendious  treatises  for  practise  ...  is  not  to  be 
disallowed." 

By  abbreviating  certain  chapters  and  abstaining  from  theori- 
zing, I  have  been  able  to  devote  considerable  space  to  the  proper 
treatment  of  very  important  subjects  without  making  a  large 
book.  The  description  of  the  management  of  normal  labor  has 
been  made  as  nearly  complete  as  possible,  no  detail,  great  or  small, 
being  overlooked.     The  importance  of  exact  and  correct  knowl- 


vi  PEEFACE 

edge  of  normal  labor  with  all  its  preventive  possibilities  is  perhaps 
better  appreciated  on  this  continent  than  in  older  countries,  be- 
cause a  kind  Providence  has  thus  far  mercifully  preserved  us  from 
the  licensed  midwife. 

In  the  consideration  of  pathological  and  operative  obstetrics 
an  effort  has  been  made  to  give  full  and  definite  directions  for 
the  treatment  of  all  the  emergencies  which  arise  in  the  practise 
of  midwifery.  The  pathological  conditions  arising  in  pregnancy, 
labor  and  the  puerperium,  and  the  relationship  between  them  and 
such  diseases  as  tuberculosis,  appendicitis,  heart  disease,  syphilis, 
gonorrhoea,  nephritis,  general  toxaemia,  etc.,  have  beeri.  fully  dis- 
cussed. 

The  Book  is  divided  into  two  parts :  I.  Physiological  Ob- 
stetrics; II.  Pathological  and  Operative  Obstetrics.  In  making 
such  a  division,  which  is  done  partly  for  teaching  purposes,  it 
is  not  presumed  that  a  definite  line  always  separates  the  normal 
from  the  abnormal  in  midwifery.  Part  I  contains  the  subjects 
of  the  third-year  course;  Part  II  contains  those  of  the  fourth-year 
course  in  the  University  of  Toronto. 

I  am  indebted  to  Dr.  Fothingham,  Dr.  Mcllwraith,  Dr.  Fenton, 
Dr.  MacMurchy,  Dr.  Goldie,  Dr.  R.  H.  Muhin  and  Dr.  Malloch 
for  kind  assistance  in  connection  with  the  reading  matter,  and 
also  to  Dr.  Edmund  E.  King,  who  took  charge  of  the  preparation 
of  the  illustrations,  and  was  assisted  by  Dr.  E.  M.  Walker.  We 
have  used  chiefly  the  specimens  and  material  in  the  University 
Museum  and  the  Burnside  Lying-in  Hospital.  The  cuts  illustrat- 
ing the  repair  of  lacerations  of  the  pelvic  floor  and  perinseum  are 
reproduced  from  drawings  from  life  in  the  Burnside,  by  Dr. 
Walker.  I  have  to  thank  Dr.  Howard  Kelly,  Dr.  Whitridge 
Williams  and  others,  for  some  illustrations  which  I  have  bor- 
rowed. I  have  also  to  thank  my  Publishers,  and  especially  Dr. 
Broome,  for  valuable  suggestions,  and  for  unvarying  kindness  and 

courtesy. 

Adam   H.   Wright. 

30  Gerhard  Street,  E.,  Toronto,  Canada. 


CONTENTS 


PART  I 


PHYSIOLOGICAL   OBSTETRICS 


CHAPTER 


I. 


-Anatomy 

The  pelvis         .... 

The  female  reproductive  organs 

External  organs 

Internal  organs 

The  mammse  or  mammary  glands 
II. — Physiology         .... 

Ovulation         .... 

Menstruation   .... 

Conception  and  generation 
III. — The  Embryo  and  Fcetus 
IV. — Pregnancy         .... 

Foetus  in  utero 

Changes  in  the  maternal  organism 

Diagnosis  of  pregnancy    . 

Signs  and  symptoms 

Differential  diagnosis  of  pregnancy 

Duration  of  pregnancy     . 

Diagnosis  of  previous  pregnancy 

Pelvimetry       .... 

Description  of  pelvimetry 

Hygiene  and    management  of  pregnancy 
-Physiology  op  Labor 

The  expelling  powers 

Stages  of  labor         ... 

Methods  of  examination 

Mechanism  of  labor 

First  position  or  left  occipito-anteri 

The  other  vertex  positions 
VI. — Management  of  Normal  Labor 

General  directions    . 

The  onset  of  labor   . 

First  stage  of  labor 

Management  of  the  second  stage  of  labor 


V.- 


PAGB 
1 
1 

6 
6 

7 
14 
15 
15 
16 
16 
18 
30 
30 
30 
38 
39 
48 
51 
53 
54 
55 
61 
65 
65 
71 
72 
77 
78 
83 
85 
85 
92 
98 
105 


Vlll 


CONTENTS 


CHAPTER  PAGE 

VII. — Normal  Labor  {Continued) 121 

Third  stage  of  labor 121 

Care  of  mother  immediately  after  labor            ....  132 

Management  of  the  babe  immediately  after  labor    .         .         .  135 

Methods  of  artificial  respiration        ......  136 

Anaesthetics  in  labor 142 

VIII. — The  Puerperal  State      ........  146 

General  conditions            ........  146 

The  care  of  the  mother    ........  153 

The  condition  and  care  of  the  babe          .....  160 

Artificial  feeding      .........  163 

Care  of  premature  infants         .......  166 

IX. —  Face    Presentations,    Breech    Presentations,    Multiple 

Pregnancies   .....*....  169 

Face  presentations  .         .         .         .         .         .         .         .169 

Management    . 172 

Brow  presentations  .         .         .         .         .         .         .         .175 

Breech  presentations        ........  175 

Mechanism  and  management 177 

Multiple  or  plural  pregnancies 185 

Twins 185 


PART  II 


PATHOLOGICAL   AND   OPERATIVE  OBSTETRICS 


X. — Diseases  of  Pregnancy 
Salivation  or  ptyalism 
Dental  caries  and  toothache 
Derangement  of  the  stomach 
Disorders  of  intestines    . 
Enteroptosis  or  gastroptosis 
Diseases  of   the  circulatory  system 
Diseases  of   the  respiratory  organs 
Nervous  diseases    ..... 
Paralysis  of  pregnancy 
Diseases  of  the  skin        .... 
XI. — Diseases  of  Pregnancy  {Continued) 

Prolapse  of  the  uterus    .         .         .         . 

Anteversion  and  anteflexion  of  the  uterus 

Retroversion  and  retroflexion 

Incomplete  retroversion  or  incomplete  retroflexion 

Hernia  of  the  uterus 

Leucorrhoea   .... 

Pruritus  vulvae 


192 
192 
193 
194 
197 
199 
200 
202 
202 
206 
207 
210 
210 
211 
213 
217 
218 
218 
220 


CONTENTS 


IX 


Painful  mammary  glands 

Myofibromata  with  pregnancy 

Diseases  of  the  decidua  and  ovum 

Pathology  of  the  chorion 

Hydatiform  mole  or  vesicular  mole 

Diseases  of  the  amnion 

Hydranuiion,  hydramnios  or  polyhydramnios 

OJigo-hydramnios  .... 

XII. — Intercurrent  Diseases  of  Pregnancy 

The  acute  infectious  diseases 

Typhoid  or  enteric  fever 

Scarlatina 

Erysipelas 

Measles 

Smallpox 

Pneumonia 

Cholera 

Tetanus 

Tetany 

Influenza 

Malaria 

Rheumatism 

Bronchocele 

Haemorrhages 

Lead  poisoning 

Mercurial  poisoning 

Tobacco  poisoning 

Factory  employment,  pregnancy  and  childbirth 

Appendicitis 

Tuberculosis 

Cardiac  diseases 

Syphilis 

Gonorrhoea     . 
XIII. — Diseases  of  Pregnancy  and  the  Puerperium 

Diseases  of  the  kidneys 

Nephritis 

Diseases  of  the  bladder 

General  toxarnia  of  pregnancy 

Eclampsia      ...... 

Acute  or  chronic  nephritis  with  eclampsia 
XIV. — Extra-Uterine  or  Ectopic  Pregnancy 

Primary  ectopic  gestation 

Haemorrhages  due  to  ectopic  gestation  . 

Secondary  ectopic  gestation  . 

Diagnosis  of  ectopic  gestation 

Differential  diagnosis  of  tubal  pregnancy 

Growing   pregnancy,  full-term  pregnancy,  dead  pregnancy 


221 
222 
225 
226 
226 
228 
228 
231 
232 
232 
232 
234 
235 
236 
236 
237 
237 
238 
238 
238 
239 
239 
240 
240 
240 
240 
241 
241 
242 
249 
257 
265 
269 
272 
272 
273 
280 
283 
294 
306 
310 
313 
316 
321 
322 
327 
329 


X  CONTENTS 

CHAPTER  PAGE 

XV. HEMORRHAGE   BEFORE,   DURING,    AND   AfTER   LaBOR         .            .  333 

Haemorrhage  before  labor 333 

Accidental  haemorrhage 333 

Treatment  for  external  accidental  haemorrhage      .         .         .  338 

Treatment  for  concealed  accidental  haemorrhage    .         .         .  340 
Placenta  praevia     .         .         .         .         .         .         .         ,         .341 

Treatment  of  placenta  praevia         ......  343 

Haemorrhage  from  cancer  of  the  cervix          ....  348 

Haemorrhage  from  a  ruptured  varix  of  the  vagina  or  vulva  349 

Post-partum  haemorrhage       .......  349 

Primary  post-partum  haemorrhage          .....  349 

Treatment      .         .         .         .         .         .         .         .         .         .  351 

Secondary  post-partum  haemorrhage      .....  355 

XVI. — Abortion  or  Miscarriage 359 

General  considerations             .......  359 

Threatened  abortion       ........  362 

Inevitable  abortion '  .         .  362 

Treatment      .         .         : 362 

Other  varieties  of  abortion     .......  372 

Deciduoma  malignum  or  chorio-epithelioma  ....  372 

XVII. — Prolonged  and  Precipitate  Labor       .....  374 

Prolonged  labor 374 

Causes  of  prolonged  labor 376 

Dry  labor       ..........  377 

Treatment  of  dry  labor           .......  382 

Difficult  occipito-posterior  positions       .....  385 

Treatment 387 

Labor  obstructed  by  faulty  conditions  of  the  soft  parts          .  392 

Precipitate  labor    .........  397 

XVIII. — Malpresentations     and     Abnormal    Conditions    of     the 

F(ETUS 399 

Shoulder,  arm,  and  transverse  presentations           .         .         .  399 

Abnormalities         .........  403 

XIX. — Abnormal   Conditions  of  the  Uterus,  its  Contents,  and 

THE  Mammary  Glands  .         .         .         .         .         .410 

Rupture  of  the  uterus   .         .         .         .         .         .         .         .  410 

Inversion  of  the  uterus  .         .         .         .         .         .         .416 

Retention  of  the  placenta  and  adhesions  of  placenta      .         .  418 

Mastitis 420 

XX. — ^The  Emotional  Element  in  the  Puerperal  Period  and 

Puerperal  Insanity 427 

Effects  of  emotional  disturbances           .....  427 

Puerperal  insanity          ........  430 

XXI. LiSTERISM    AND    OBSTETRICS 433 

Puerperal  fever  or  puerperal  septic  infection           .         .         .  435 

Nature  of  puerperal  infection         ....••  436 

How  does  the  infection  take  place          .         .         .         .         •  437 


CONTENTS 


XI 


CHAPTER 

Bacteriology        .... 

Varieties  of  puerperal  infection    . 

Pathology 

Symptoms  of  puerperal  infection 

Treatment  of  puerperal  infection 
XXII. — Puerperal  Infection  (Continued) 

Phlegmasia  alba  dolens 

Gonorrhoeal  infection 
XXIII. — Deformities  of  the  Bony  Pelvis  and  Injuries  to  the 
Child  During  Delivery 

Causes  and  forms  of  deformity 

Contracted  pelvis 

Treatment 

Injuries  to  child  during  delivery 

Abnormalities  and  diseases  of  the  new-born  child 
XXIV. — Obstetrical  Operations      .... 

General  considerations         .... 

General  operations       ..... 

Repair  of  lacerations  of  the  genital  canal     . 

Lacerations  of  the  vagina    .... 

Lacerations  of  the  pelvic  floor  and  perinseum 

Induction  of  abortion  .... 

Induction  of  premature  labor 

Accouchement  force     ..... 

Cervical  incisions         ..... 

Version        ....... 

XXV. — Obstetrical  Operations  (Continued)  . 

Delivery  with  the  forceps    .... 

Indications  ...... 

Kinds  of  forceps  ..... 

The  Milne  Murray  axis-traction  forceps 

The  Porter  Mathew  axis-traction  forceps     . 
XXVI. — Major  Obstetrical  Operations 

Csesarean  section 

Porro's  operation 

Hysterectomy 

Symphysiotomy 

Operation  for  ectopic  pregnancy 

Embryotomy 


PAGE 

438 
440 
443 
445 
455 
473 
473 
476 

480 
480 
482 
484 
489 
491 
496 
496 
499 
508 
509 
510 
519 
520 
522 
528 
530 
534 
534 
535 
539 
543 
546 
559 
559 
560 
561 
561 
563 
563 


LIST  OF   ILLUSTRATIONS 


Abdomen  of  primipara  showing  strise.     (Fig.  189) 

Accidental  haemorrhage.     (Fig.  125)        ..... 

Accidental  ha?morrhage,  concealed.     (Fig.  126) 

Anencephalus,  with  meningocele  and  spina  bifida.     (Fig.  134) 

Artificial  respiration,  Byrd's  method  (first  part).     (Fig.  91) 

Artificial  respiration,  Byrd's  method  (second  part).     (Fig.  92) 

Artificial  respiration,  Sylvester's  method  (first  part).     (Fig.  89) 

Artificial  respiration,  Sylvester's  method  (second  part).     (Fig.  90) 

Bags,  Voorhees'  dilating.     (Fig.  183) 

Balloon,  Champetier  de  Ribes.     (Fig.  181) 

Balloon,  Champetier  de  Ribes,  ready  for  introduction.     (Fig.  182) 

Bandage,  many-tailed,  applied  for  phlegmasia  dolens.     (Fig.  167) 

Bandage,  many-tailed,  partially  applied.     (Fig.  166) 

Bandage,  many-tailed,  T-bandage.     (Fig.  165) 

Barkpr,  Fordyce.     (Fig.  154)  .... 

Basylist,  Simpson's,  articulated.     (Fig.  222)  . 

Basylist,  Simpson's,  disarticulated.     (Fig.  221) 

Belly,  pendulous,  of  a  multiparous  woman.     (Fig.  44) 

Bladder,  empty  after  labor.     (Fig.  98) 

Bladder,  empty  before  labor.     (Fig.  64) 

Bladder,  full  after  labor.     (Fig.  99) 

Bladder,  full  before  labor.     (Fig.  65) 

Blood,  normal.     (Fig.  163)      . 

Blunt  hook,  Braun's.     (Fig.  223)    . 

Blunt  hook,  Braun's,  decapitation  with.     (Fig.  224) 

Bossi's  dilator.     (Fig.  184) 

Breast  of  pregnancy.     (Fig.  149)    . 

Breast,  mastitis.     (Fig.  150) 

Breech  presentation.     (Fig.  62) 

Cancer  of  the  cervix  with  pregnancy.     (Fig.  129) 

Cancer  of  the  cervix  with  pregnancy,  showing  embryo.     (Fig.  130) 

Cephalotribe,  Tamier's.     (Fig.  220) 

Cervix,  manual  dilatation  of.     (Fig.  180) 

Chair,  Soudan  labor.     (Fig.  77)       . 

Chair,  Soudan  woman  in  labor  in.     (Fig.  78) 

Chair,  Soudan  woman  in  labor  in.     (Fig.  79) 

Chart,  abnormal  involution  line.     (Fig.  96)    . 


PAGE 

536 
334 
335 

401 
139 
140 
137 
138 
527 
525 
526 
476 
475 
474 
434 
568 
567 

36 
150 
108 
151 
108 
470 
568 
569 
428 
421 
422 

77 
347 
348 
567 
524 
119 
119 
120 
148 


XIV 


LIST    OF    ILLUSTEATIOKS 


118) 
(Fig. 


119) 


Chart,  abnormal  involution  line.     (Fig.  97)    . 
Chart,  high  temperature  after  curettement.     (Fig.  155) 
Chart,  high  temperature  from  acute  indigestion.     (Fig.  161) 
Chart,  influenza.      (Fig.  160)  ..... 

Chart,  normal  involution  line.     (Fig.  95) 
Chart,  puerperal  syphilitic  fever.     (Fig.  117) 
Chart,  "queer"  from  unknown  causes.     (Fig.  159) 
Chart,  rise  of  temperature  from  sore  nipples.     (Fig.  151) 
Chart,  septicaemia.     (Fig.  158) 
Cord,  cutting  the.     (Fig.  88)  ... 

Cord,  umbilical,  section  through.     (Fig.  22)   . 
Cranioclast,  Braun's.     (Fig.  218)    . 
Cranioclast,  head  crushed  by.     (Fig.  219) 
Decidua  reflexa,  diagram  showing  formation  of.     (Fig.  17)     . 
Decidua  reflexa,  diagram  showing  formation  of.     (Fig.  18)     . 
Ectopic  gestation,  broad  ligament  or  extraperitoneal.     (Fig.  123) 
Ectopic  gestation,  interstitial,  rupture.     (Fig.  120)         .         .    , 
Ectopic  gestation,  rupture  of  tube,  corpus  luteum.     (Fig 
Ectopic  gestation,  rupture  of  tube,  thickened  decidua. 
Ectopic  gestation,  uterine  decidua.     (Fig.  122) 
Embryos  from  second  month.     (Figs.  27  to  29) 
Embryos  from  fourth  and  fifth  weeks.     (Figs.  23  to  26) 
.  Embryo,  transverse  section  through.     (Fig.  19) 

Exomphalos.     (Fig.  139) 

Face  presentation,  delivery  of  head  in.  (Fig.  103) 
Fibroids,  pregnancy  with  numerous.  (Fig.  113)  . 
Fibroids,  obstructing  pregnancy.     (Fig.  114) 

Foetal  circulation.     (Figs.  37,  38) Facing 

Foetuses,  composite  of,  at  two,  three,  five,  seven  and  nine  months. 

(Figs.  30  to  34) 25 

Foetus,  macerated.     (Fig.  142) 409 

Foetus,  meningocele.     (Fig.  141) 408 

Foetus  papyraceous.     (Fig.  109)     .         . 187 

Foetus,  with  ascites.     (Fig.  133) 400 

Forceps,  articulated  (Mathew).     (Fig.  205) 547 

Forceps,  blades  and  traction  rods  held  in  hands  before  application 

(Mathew).     (Fig.  206) 548 

Forceps,  front  view  of  blades  and  rods  (Mathew).  (Fig.  203)  .  .  545 
Forceps,  introduction  of  first  blade  (Mathew).  (Fig.  207)  .  .  .549 
Forceps,  introduction  of  second  blade  (Mathew).     (Fig.  208)         .         .     550 

Forceps,  introduction  of  right  blade.     (Fig.  212) 554 

Forceps,  left  blade  in  place.     (Fig.  211) 553 

Forceps,  lock  of  English.     (Fig.  199) 542 

Forceps,  lock  of  French.     (Fig.  200) 543 

Forceps,  locked.     (Fig.  213) 655 

Forceps,  locked,  Pajot's  maneuver.     (Fig.  202) 544 

Forceps,  locked  and  block  and  handle  adjusted  (Mathew).     (Fig.  209)  .     551 


PAGE 

149 

441 

451 

450 

147 

268 

449 

423 

448 

136 

23 

565 

566 

19 

19 

326 

317 

314 

315 

324 

24 

24 

20 

406 

172 

223 

224 

28 


LIST    OF    ILLUSTRATIONS 


XV 


Forceps,  Mathew's  axis  traction,  parts  sciparated. 
Forceps,  ordinary  lonjj;,  introduction  of  left  blade. 
Forceps,  side  view  of  blades  and  rods.     (Fig.  204) 
Forceps,  Simpson's,  cephalic  curve.     (Fig.  197) 
Forceps,  Simpson's,  pelvic  curve.     (Fig.  198) 
Gertrude  baby  suit.     (Fig.  93) 
Head,  birth  of.     (Fig.  71)       . 

(Fig.  72)  ■      . 

(Fig.  73)       . 

(Fig.  74)       . 

(Fig.  75)       . 

(Fig.  76)       . 

(Fig.  35) 
(Fig.  36) 


(Fig.  214) 
(Fig.  210) 


Head,  birth  of. 
Head,  birth  of. 
Head,  birth  of. 
Head,  birth  of. 
Head,  birth  of. 
Head,  child's,  at  term 
Head,  child's,  at  term 


Head,  controlling  passage  of  through  vulva.     (Fig.  66) 

Head,  controlling  passage  of  through  vulva.     (Fig.  67) 

Head,  presentation.     (Fig.  61) 

Hegar's  sign.     (Fig.  47) 

Holmes,  Oliver  Wendell.     (Fig.  157)       . 

Hydatidiform  mole.     (Fig.  115) 

Incarceration  of  retroflexed  pregnant  uterus.     (Fi 

Labor,  room  prepared  for.     (Fig.  63) 

Leg-holder,  Robb's.     (Fig.  201)      . 

Leucocytosis.     (Fig.  164) 

Leucopoenia.     (Fig.  162) 

Lithopsedion,  ectopic  gestation.      (Fig.  124) 

Lithotomy  position,  patient  prepared  for  operation 


112) 


(Fig.  192) 


Lithotomy  position,  parts  partially  exposed.     (Fig.  193) 

Lord  Lister.     (Fig.  152) 

Murphy  binder.     (Fig.  102)    . 

Nabothian  glands.     (Fig.  13) 

Os,  parous  external.     (Fig.  12) 

Os,  virginal  external.     (Fig.  11) 

Ovum,  human.     (Fig.  15) 

Palpation,  abdominal,  deep  pelvic  grip.     (Fig.  60) 

Palpation,  abdominal,  fundal  grip.     (Fig.  55) 

Palpation,  abdominal,  Mcllwraith's  grip.     (Fig.  58) 

Palpation,  abdominal,  Pawlic's  grip.     (Fig.  59) 

Palpation,  abdominal,  second  umbilical  grip.     (Fig.  57) 

Palpation,  abdominal,  umbilical  grip.     (Fig.  56)    . 

Pasteur,  Louis.     (Fig.  156) 

Pelvic  floor  and  perinseum,  sutures  in  tears.     (Fig.  171) 
Pelvic  floor,  distended,  showing  superficial  muscles.     (Fig.  70) 
Pelvic  floor  from  above.     (Fig.  68) 
Pelvic  floor  from  below.     (Fig.  69) 
Pelvic  floor,  sutures  in  tear.     (Fig.  170) 
Pelvic  floor,  tear,  bilateral.     (Fig.  169) 


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XVI 


LIST    OF    ILLUSTEATIONS 


Pelvic  floor,  tear,  correct  result  after  tying  suture.     (Fig.  175) 

Pelvic  floor,  tear,  fault  after  tying  suture.     (Fig.  173)    . 

Pelvic  floor,  tear  on  right  side.     (Fig.  168)     . 

Pelvic  floor,  tear,  suture  improperly  introduced.     (Fig.  172) 

Pelvic  floor,  tear,  suture  properly  introduced.     (Fig.  174) 

Pelvimetry,  antero-posterior  measurement.     (Fig.  51)    . 

Pelvimetry,  intercristal  measurement.      (Fig.  50)    . 

Pelvimetry,  interspinous  measurement.     (Fig.  49) 

Pelvis,  normal  female.     (Fig.  1)      . 

Pelvis,  normal  female,  showing  diameters  of  superior  strait.     (Fig.  2) 

Perforation  of  head.     (Fig.  217)      ..... 

Perforator,  Simpson's.     (Fig.  215)  .... 

PerinEeum,  tear  extending  into  rectum,  sutures.     (Fig.  177) 

Perinseum,  tear  extending  into  rectum,  some  sutures  tied.     (Fig.  178) 

Perinaeum,  tear  extending  into  rectum,  all  sutures  tied.     (Fig.  179) 

Perinseum,  tear,  sutures.     (Fig.  176) 

Placenta,  battledore,  foetal  surface.     (Fig.  137) 

Placenta,  battledore,  maternal  surface.     (Fig.  136) 

Placenta,  being  expelled.     (Fig.  82) 

Placenta,  diagram  of.     (Fig.  21)     . 

Placenta,  double.     (Fig.  135)  .... 

Placenta  in  uterus  after  birth  of  child.     (Fig.  80) 

Placenta  prsevia,  (complete).     (Fig.  128) 

Placenta  praevia,  (incomplete).     (Fig.  127) 

Placenta  separated  and  pushed  partially  into  vagina.     (Fig.  81) 

Placenta,  velamentous  insertion.     (Fig.  138) 

Placental  site  near  fundus.     (Fig.  83)     . 

Prague  method  of  extracting  the  head.     (Fig.  104) 

Pregnancy,  five  weeks.     (Fig.  39)  . 

Pregnancy,  two  months.     (Fig.  40) 

Pregnancy,  three  months.     (Fig.41) 

Pregnancy,  five  months,  showing  placenta  and  sack  containing  foetus 

(Fig.  42) 

Pregnancy,  five  months,  cord  around  neck  and  arm.     (Fig.  140) 
Pregnancy,   full   term,   showing  placenta  and  sack  containing  foetus 

(Fig.  43) 

Scissors,  Smellie's.     (Fig.  216)        .... 
Section,  sagittal,  of  a  new-born  babe.     (Fig.  3) 
Section,  sagittal,  of  a  five-year  old  girl.     (Fig.  4)   . 
Section,  sagittal,  of  a  nine-year  old  girl.     (Fig.  5) 
Section,  sagittal,  of  an  adult  female  pelvis.     (Fig.  6) 
Semmelweiss.     (Fig.  153)        .... 
Sheet  sling,  first  stage  in  making.     (Fig.  194) 
Sheet  sling,  second  stage  in  making.     (Fig.  195) 
Sheet  sling  applied.     (Fig.  196) 
Shoulder-jaw  traction.     (Fig.  105) 
Shoulder-jaw  traction.     (Fig.  106) 


LIST    OF    ILLUSTRATIONS 


xvii 


Shoulder-jaw  traction.     (Fig.  107) 

Simpson,  Sir  James  Y.     (Fig.  94)  . 

Smallpox,  babe  died  in  utero  from.     (Fig.  IIG) 

Snively  breast-binder.     (Fig.  100) 

Snively  breast-binder,  applied.      (Fig.  101)     . 

Snively  stocking-drawers.     (Fig.  190)     . 

Snively  stocking-drawers,  pattern.     (Fig.  191) 

Tamponade,  uterine  after  labor.     (Fig.  145) 

Triplets  from  two  eggs.     (Fig.  110) 

Triplets  from  three  eggs.     (Fig.  Ill) 

Tubal  abortion.     (Fig.  121)    .... 

Tubal  mucosa,  longitudinal  folds  of.     (Fig.  14) 

Twins,  locked.     (Fig.  132)      .... 

Uterus  and  appendages  of  a  young  child.     (Fig.  8) 

Uterus  and  appendages  of  a  fourteen-year  old  girl.     (Fig.  9) 

Uterus  and  appendages  of  a  twenty-one  year  old  multipara.     (Fig.  10) 

Uterus,  bimanual  examination  showing  bellying.     (Fig.  46) 

Uterus,  bimanual  examination  showing  no  enlargement.     (Fig.  45) 

Uterus,  complete  inversion.     (Fig.  148)  .... 

Uterus,  height  at  different  periods  of  pregnancy.     (Fig.  48) 

Uterus,  lined  by  decidua  containing  a  seven-day  ovum.      (Fig.  16) 

Uterus,  partial  inversion,  external  view.     (Fig.  147) 

Uterus,  partial  inversion,  internal  view.     (Fig.  146) 

Uterus,  pregnant,  section  of,  after  retraction.     (Fig.  54) 

Uterus,  pregnant,  section  of,  before  retraction.     (Fig.  53) 

Uterus,  pregnant  seven  months,  front  wall  removed.     (Fig.  85) 

Uterus,  pregnant  seven  months,  placenta  and  membranes  turned  to 

left.     (Fig.  86)     . 
Uterus,  pregnant  seven  months,  posterior  wall  removed.     (Fig.  87) 
Uterus,  pregnant  seven  months,  showing  hei; 

lopian  tubes.     (Fig.  84) 
Uterus,  seventeen  days  pregnant.     (Fig.  20) 
Vagina  ballooned.     (Fig.  7)    . 
Vagina,  rupture  of.     (Fig.  143) 
Version,  bipolar  podalic.     (Fig.  188) 
Version,  external  cephalic.     (Fig.  185)   . 
Version,  internal  podalic.     (Fig.  186) 
Version,  transverse  presentation.     (Fig.  187) 
Vulvar  pad.     (Fig.  52)   .... 
Walcher's  position.     (Fig.  214) 


ght  of  fundus  above  Fal- 


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PART   I 
PHYSIOLOGICAL    OBSTETEICS 


CHAPTER  I 

ANATOMY 

GENERAL  DESCRIPTION 

The  Pelvis. — The  bony  pelvis  consists  of  four  bones,  the  ossa 
innominata,  the  sacrum,  and  the  coccyx.  In  early  life  the  os 
innominatum  has  three  bones,  the  ilium,  the  ischium,  and  pubes, 


Fig.  1. — Normal  Female  Pelvis  (Williams),      x  ^. 

united  by  a  Y-shaped  piece  of  cartilage  with  its  center  in  the  acetab- 
ulum. These  unite  at  about  the  twentieth  year.  The  last  lumbar 
vertebra  is  important,  especially  in  cases  of  deformed  pelvis.  The 
pelvis  is  divided  into  two  parts;  the  upper,  or  false  pelvis — that 


2  ANATOMY 

portion  above  the  brim ;  the  true  pelvis — that  portion  below  the 
brim. 

The  brim,  or  inlet,  is  formed  by  the  upper  margin  of  the  pubes 
in  front,  the  ilio-pectineal  line  on  either  side,  and  the  upper  and 
anterior  margin  of  the  sacrum  behind. 

The  cavity  of  the  pelvis  is  bounded  by  the  sacrum  and  the  coc- 
cyx behind,  the  pubic  bones  in  front,  the  inner  surfaces  of  the 
innominate  bones  with  the  sacro-sciatic  ligaments  and  the  muscles 
attached  to  them  at  the  sides.  The  outlet  is  lozenge-shaped  and 
is  bounded  behind  by  the  sacro-sciatic  ligaments    converging  to 


Fig.  2. — Normal  Female  Pelvis  showing  Diameters  of  the  Superior 
Strait  (Williams).      x  ^. 

the  tip  of  the  coccyx,  at  each  side  by  the  tuber  ischii,  and  in  front 
by  the  rami  of  ischia  and  pubes  converging  to  the  lower  margin  of 
the  symphysis  pubis.  The  pelvic  brim  is  sometimes  called  the 
superior  strait;  the  outlet,  the  inferior  strait. 

Differences  in  Sexes. — The  female  pelvis  differs  from  the  male 
in  the  following  respects :  it  is  shallower,  wider  and  less  funnel- 
shaped,  smoother,  thinner,  weaker;  the  fossa  of  the  ihum  is  gen- 
erally smaller  and  shallower ;  the  rami  of  the  pubes  and  ischia  are 
more  everted;  the  pubic  spines  are  farther  apart;  the  diameters 
at  the  inlet  are  greater,  especially  the  transverse;  the  inlet  is 
rounder  and  the  pubic  arch  more  open. 

The  plane  of  the  brim,  in  the  erect  position,  is  more  nearly 


GENE IJ AT.    DESCRIPTION 


vortical  than  liorizontal.  ]t  niakos  an  aiv^lc  of  sixty  degrees  with 
the  liorizoii.  'I'lic  promontory  of  the  sacrum  is  about  3f  inches 
(9  cm.)  above  the  i)ul)es  when  the  body  is  erect.  In  pregnancy, 
or  in  the  case  of  a  large  abdominal  tumor,  the  pelvic  inclination 
is  diminished. 

Articulations  of  the  Pelvis. — Sdcro-iluic  syitchrondrosis.  The 
bones  are  united  by  cartilages,  but  in  adult  women,  especially  in 
pregnancy,  a  synovial 
membrane  intervenes 
and  a  small  degree  of 
movement  is  allowed. 

Sy7nphysis  Pubis. 
The  fibro-cartilage  is 
thi(!ker  in  front  than 
behind  and  a  small 
synovial  membrane 
is  foimd  in  the  back 
part. 

Sacro-c  occygcal 
Ariiculation.  There 
is  a  cartilage  and  a 
synovial  membrane 
between  sacrum  and 
coccyx.  During  preg- 
nancy, cartilages  and 
fibrous  structures  be- 
come swollen  and 
softened ;  the  syno- 
vial cavities  become 
extended  and  the 
mobility  increased. 

Pelvic  Planes. — 
These  are  imaginary 

levels  at  any  portion  of  the  pelvic  circumference  of  the  inlet, 
cavity,  outlet,  etc.,  of  the  pelvis. 

Plane  of  Inlet,  or  Brim.     This  extends   from   the   top   of   the 
sacrum  to  the  most  prominent  point  of  the  symphysis  pubis. 

Median  Plane.     This  extends  from  the  center  of  sacrum  to  the 
center  of  the  symphysis  pubis,  etc. 

Plane  of  Outlet,     This  extends  from  the  lower  part  of  the  sym- 


FiG.  3. — Sagittal  Section,  Five-year-old  Girl. 

;,    uterus;    6,   bladder;    v,   vagina   slightly  distended 
with  a  tampon.    (Primrose,  Tor.  Univ.  Museum.) 


AXATOMY 


physis  pubis  to  the  lowest  point  of  the  sacrum,  etc.,  or  the  lowest 
point  of  coccyx,  according  to  some. 

Axis  of  Pelvis. — This  is  an  imaginary  line  indicating  the  course 
of  the  center  of  the  foetal  head  as  it  passes  through  the  pelvis,  some- 
times called  the  circle  of 
Carus,  although  it  is  not 
really  a  circle  nor  an  arc 
of  one.  On  the  inner  sur- 
face of  the  ischium  there 
are  two  planes  separated 
by  a  hne  passing  from  the 
ilio-pectineal  eminence  to 
the  spine  of  the  ischium, 
called  the  anterior  and 
posterior  planes  of  the 
ischium.  Two  other 
planes  are  formed  by  the 
inner  surface  of  the  pubic 
bones  in  front,  and  by  the 
upper  portion  of  the  sac- 
rum behind,  both  directed 
downward  and  backward. 
These  planes,  in  conjunc- 
tion with  the  spines  of  the 
ischia,  are  supposed  by 
some  to  assist  in  rotating 
the  fcetal  head  in  delivery. 
The  Pelvis  in  Infancy  and  Childhood. — The  pelvis  is  funnel- 
shaped,  and  the  pubic  arch  forms  a  more  acute  angle;  the  tubera 
ischii  are  relatively  nearer  together  than  in  the  adult.  It  is  small 
even  in  proportion  to  the  size  of  the  child.  The  iliac  fossae  are 
flatter,  more  upright,  and  their  surfaces  look  more  forward;  the 
maximum  distance  between  the  iliac  crests  is  hardly  greater  than 
that  between  the  anterior  superior  spines.  The  sacrum  is  narrower 
in  proportion  than  in  the  adult  pelvis. 

The  three  portions  of  the  innominate  bones  are  not  united  until 
about  the  twentieth  year.  The  pelvis  is  largely  developed  at  the 
time  of  puberty,  partly  by  the  development  of  the  different  bones 
and  partly  by  the  action  of  mechanical  forces;  the  wings  of  the 
sacrum,  especially,  grow,  making  the  transverse  diameter  greater. 


Fig.    4. — Sagittal    Section    through    Body 
OF  Newly  Born  Child  (Williams). 


GENERAL    DESCRIPTIOX 


The  pressure  produced  by  the  weight  of  the  body,  transmitted 
through  the  sacrum,  assists  in  moulding  the  bones.  The  pressure 
and  tension  of  muscles  also  assist. 

The  Pelvic  Floor. — The  structures  closing  the  pelvis  form  a  com- 
plete diaphragm  in  which  there  are  three  faults  or  slits  (Berry 
Hart),  the  urethra,  the  vagina,  and  the  rectum.  The  vagina  is  the 
most  important  of  these  shts,  from  an  obstetrical  point  of  view. 
The  outlet,  when  com- 
pared with  the  capa- 
cious vaginal  cavity, 
may  be  likened  to 
the  narrow  vent  of  a 
funnel  with  a  wide 
mouth  (Hunter 
Robb). 

The  floor  of  the 
pelvis  includes  on  each 
side :  the  visceral  layer 
of  the  pelvic  fascia 
(rectal,  recto-vesical, 
and  vesical  portion)  ; 
the  parietal  layer  of 
pelvic  fascia  (also 
called  "deep  layer  of 
triangular  liga- 
ment") ;  the  triangu- 
lar ligament;  the 
fascia  of  Colles;  the 
following  muscles  : 
coccygeus,  pyriformis, 
levator  ani,  a  portion 
of  obturator  internus, 
deep  and  superficial 
transversus       perinaei 

muscles,    constrictor    vaginae,    and  external    sphincter    ani;    the 
skin  and  subcutaneous  tissue. 

The  perineal  body  (so-called)  is  the  triangular  body  between 
the  vagina  arid  rectum,  the  skin  between  the  two  forming  its  base, 
about  1  inch  (2.5  cm.)  in  length.  The  apex  is  about  H  inches  (4 
cm.)  above,  where  the  walls  of  the  rectum  and  vagina  unite.     The 


Fig.  5. — Sagittal  Frozen  Section,   Nine-year- 
old  Girl. 

V,  vagina;  u,  uterus;  b,  bladder.     (Primrose,   Tor. 
Univ.  Anatomical  Museum.) 


A^TATOMY 


following  structures   are  found  in  this  perineal  body:  the  deep 
fascia  (two  layers) ;  a  part  of  sphincter  ani  muscle ;  a  part  of  levator 

ani  muscle;  a  part  of  con- 
strictor vaginge  muscle;  the 
junction  of  trans  versus  peri- 
nsei  muscles ;  some  connective 
tissue,  fat,  and  subcutane- 
ous fascia ;  and  the  skin. 

The  sheets  of  fascia  (es- 
pecially the  recto  -  vesical 
fascia)  are  the  strongest 
structures  in  the  pelvic  floor 
and  probably  form  the  main 
support  of  the  pelvic  con- 
tents. The  chief  function  of 
the  levator  ani  muscle  is 
to  pull  forward  and  upward 
the  post-vaginal  structures 
of  the  pelvic  floor,  especially 
the  lower  extremities  of  the 
rectum  and  vagina,  and  to 
form  to  some  extent  sphinc- 
ters for  both. 

Note. — The  pelvic  floor 
consists  of  two  parts,  the 
structures  of  which  meet  in 
a  median  rhaphe.  Injuries  to  the  pelvic  floor,  during  labor,  gen- 
erally occur  on  one  or  both  sides  of  the  median  line. 


Fig.  6. — Sagittal  Section  through  Adult 
Woman  (Kelly),  reduced  to  the  Same 
Size  as  Fig.  3  for  Comparison  (Wil- 
liams) 


THE  FEMALE  REPRODUCTIVE  ORGANS 

The  female  reproductive  organs  are  divided  into  the  external, 
or  copulative  organs;  the  internal,  or  formative  organs. 


EXTERNAL  ORGANS 

Mens  Veneris. — This  is  the  cushion  of  adipose  and  fibrous  tissue 
lying  over  the  symphysis  and  horizontal  rami  of  the  pubes. 

Labia  Majora. — These  are  the  two  sides  of  the  vulva  extending 
from  the  mons  veneris  in  front  to  the  fourchette  behind, 


TUK    FKMALI-]    KKIM.'ODLX'TIVE    ORGANS  7 

Labia  Minora,  or  Nymphae. —  'I'licso  aro  two  folds  of  skin  (not 
mvicous  inciiibraiu')  exist iiiu'  insiilc  of  the  labia  niajora,  uniting 
anteriorly  in  the  middle  line  where  they  I'onn  the  prepuce  of  the 
clitoris. 

Clitoris. — This  is  a  small  erectile  tubercle,  the  homologue  of  the 
penis  in  the  male,  about  half  an  inch  below  the  anterior  commissure 
of  the  labia  niajora. 

Vestibule. — This  is  a  triangular  surface  covered  with  mucous 
membrane,  bounded  at  its  apex  by  the  clitoris,  on  cither  side  by 
the  labia  minora,  and  having  at  its  base  the  anterior  margin  of  the 
opening  of  the  vagina.  The  urethral  aperture  is  situated  at,  or  a 
little  above,  the  center  of  the  base. 

Fourchette. — This  is  the  bridge  of  the  skin  beliind  the  vulva. 


INTERNAL   ORGANS 

Urethra. — This  is  the  canal  H  inches  (4  cm.)  in  length,  through 
which  the  bladder  is  emptied. 

Vagina. — The  vagina  is  the  canal  in  the  pelvic  floor  which 
forms  the  communication  between  the  external  and  the  inter- 
nal organs  of  generation. 
The  vaginal  orifice  lies 
between  the  vestibule  and 
the  fourchette,  and  is 
wholly  or  partially  cov- 
ered by  hymen.  The  an- 
terior wall  is  closely  re- 
lated to  the  base  of  the 
bladder ;  the  posterior  wall 
to  the  rectum;  the  sides 
to  the  broad  ligaments 
and  pelvic  fascia.  The 
vulvo-vaginal  glands  are 
situated  near  the  posterior 
part  of  the  vaginal  orifice. 
The  fossa  navicularis,  sit- 
uated between  the  hymen  and  the  perinteum,  is  a  small  depres- 
sion which  disappears  after  child-bearing. 

Uterus. — The  uterus  is  a  hollow  muscle,  an  incubator  chamber, 
for  the  reception  and  development  of  oosperms  (Bland  Sutton)^ 


Fig.   7. — Vagina  Ballooned  by  Gaxjze-Pack- 

ING,      SHOWING     A     LaRGE      CaVITY      WITH      A 

Small  Outlet. 


ANATOMY 


^'' 


y 


Fig.  8. — Uterus  and  Appendages  of 
Young  Child  (Williams),      x  f . 


situated  behind  the  bladder  and  in  front  of  the  rectum.  The 
anterior  surface  is  somewhat  flatter  than  the  posterior.  In  infancy 
and  childhood  it  is  small  and  the  neck  is  larger  than  the  body. 

At    puberty    there  is   a   re- 
f(\  \     ~^   "^ '      "^      markable    development,  the 

uterus  increasing  about 
50  per  cent,  during  men- 
struation. After  the  meno- 
pause it  atrophies.  The 
virgin  uterus  is  2^  inches  (7 
cm.)  long  and  weighs  about 
1  ounce  (.31  gm.). 

The  uterus  is  divided 
into  three  regions :  the  fundus  uteri,  the  arched  portion  above 
the  straight  line  joining  the  ends  of  the  oviducts ;  the  corpus  uteri, 
the  portion  triangular  in  shape  between  the  Fallopian  tubes  and 
the  cervix;  the  cervix  uteri,  the  lower  fusiform  portion. 

Structure.  The  wall  of  the  uterus  is  made  up  of  three  layers, 
peritoneal  or  serous,  muscular,  and  mucous. 

Peritoneal.  The  peritonseum  passes  from  the  bladder  on  to 
the  uterus  at  the  isthmus,  up  the  anterior  surface  of  the  fundus, 
thus  forming  the 
utero-vesical  pouch. 
It  then  passes  over 
the  fundus,  down 
the  posterior  surface 
of  the  uterus  and 
a  small  portion  of 
the  vagina  (less  than 
1  inch)  and  then 
up  the  anterior  wall 

of  the  rectum,  thus  forming  the  pouch  of  Douglas.  When  the 
bladder  is  distended  the  peritongeum  on  the  anterior  surface  of 
the  uterus  is  pulled  up  to  the  fundus.  Normally  the  utero-vesi- 
cal pouch  and  the  pouch  of  Douglas  contain  no  small  intestine. 

Muscular.  The  muscular  wall  of  the  uterus  is  about  \  inch 
(1  cm.)  thick  and  consists  of  interlacing  bundles  of  smooth  mus- 
cular fibers.  Two  layers  are  described  (sometimes  three).  A 
thin  external,  or  subperitoneal  layer,  supplying  strands  which  pass 
into  the  ligaments  of  the  uterus ;  an  internal  layer,  thick,  contin- 


^^^ 


a 


Fig.  9. 


-Uterus  and  Appendages  of  Fourteen- 
year-old  Girl  (AYilliams).      x  f . 


TIIK    FEMALK    KEl'lJODrCTI  VE    OlKiAXS 


9 


uoiis  with  the  muscle  oi  the  vanilla.  Elastic  and  ordinary  con- 
nective tissue  exists  between  the  muscle  bundles.  There  are  spe- 
cial muscular  rinf2;s  around  the  inner  ends  of  the  l''allopian  tubes, 
the  OS  internum,  and  the  os  externum. 

Mucus.     The  mucosa  of  the  body  is  about  -j^  to  jt^  inch  thick 
under  ordinary  circumstances,  but  grows  thicker  before  the  men- 


FiG.  10. — Uterus  and  Appendages  of  Twenty-year-old  Multipara 
(Williams).      x  f . 

strual  period.  It  is  implanted  directly  on  the  muscular  wall 
without  the  intervention  of  a  submucous  layer.  The  lining  epi- 
thelium consists  of  ciliated  columnar  cells.  The  glands,  crypts, 
or  follicles,  single  or  branched,  are  tubular,  and  their  openings 
are  visible  on  shght  magnification.  The  interglandular  tissue, 
composed  of  tissue  of  a  low  or  embryonic  type,  forms  the  main 
portion  of  the  mucosa.  The  mucosa  of  the  cervix  is  continuous 
with  that  of  the  corpus,  there  being  no  definite  line  of  demarcation 


Fig.  11. — Virginal  External  Os 
(Williams). 


Fig.  12. — Parous  External  Os 
(William.s). 


between  them.     It  is  folded,  however,  to  form  the  arbor  vitse — 
j  e.,  a  vertical  ridge  on  the  anterior  and  posterior  wall,  with  branch- 


10  ANATOMY 

ing  ridges  extending  from  it.  The  epithelium  is  columnar,  ciliated 
on  the  ridges,  but  not  between  them.  The  glands  are  racemose 
and  lined  by  columnar  epithelium. 

Cavity  of  Uterus.  The  body  is  triangular  in  shape,  the  open- 
ings of  Fallopian  tubes  being  at  the  upper  angles,  and  the  os  inter- 
num at  the  lower  angle.  The  anterior  and  posterior  walls  are  in 
contact.  Its  capacity  is  |  to  1  dram.  The  neck  is  fusiform. 
On  the  anterior  and  posterior  walls  are  longitudinal  ridges,  the 
arbor  vitse  uterina.     The  cervical  glands  are  racemose  and  extend 


Fig.  13. — Nabothian  Follicles;  Cyst-like   Bodies   from  Obstruction  op 
THE  Ducts  op  the  Cervical  Gland  j.     (Tor.  Univ.  Museum.) 


from  the  surface  of  the  mucosa  into  the  stroma.  When  their 
ducts  are  occluded  cysts  are  formed  which  are  called  Nabothian 
follicles  or  ovula  Nabothi. 

Blood-Vessels.  The  ovarian  arteries,  from  the  aorta  close 
to  the  renal  arteries  (the  right  ovarian  frequently  from  the  right 
renal  artery),  pass  between  the  layers  of  the  broad  ligament, 
running  tortuously  through  it  to  the  upper  angle  of  the  uterus, 
where  they  anastomose  with  the  uterine  arteries.  In  their  course 
branches  are  given  off  to  supply  the  ovaries.  Fallopian  tubes,  and 
round  ligaments.  The  uterine  arteries,  from  the  anterior  division 
of  the  internal  iliac,  pass  between  the  layers  of  the  broad  ligament 


THE    FEMALE    T^EPTJODUOTTVE    OKOAXS  11 

toward  the  cervix.  After  ,iii\in.<i;  off  branches  to  the  cervix  wliich 
anastomose  with  tiiosc  of  its  fellow  on  the  opposite  side  and  with 
branches  of  the  vaginal  artery  lower  down,  each  artery  on  its  own 
side  passes  upward,  supplying'  the  body  of  the  uterus,  its  terminal 
branches  anastomosing  with  those  of  the  ovarian  artery.  The 
vaginal  arteries, ivom  the  anterior  division  of  the  internal  iliac,  anas- 
tomose with  the  low(>r  Ijranches  of  the  uterine.  The  internal  pudic 
arteries,  from  the  anterior  division  of  the  internal  iliac,  supply  the 
perinaeum. 

Lymphatics.  The  lymphatics  of  the  external  genitals  and  the 
lower  portion  of  the  vagina  terminate  in  the  inguinal  glands ;  those 
of  the  upper  portion  of  the  vagina  and  cervix  in  the  hypogastric 
glands ;  and  those  of  the  body  of  the  uterus  in  the  lumbar  glands. 

Nerves.  The  nerve  supply  of  the  uterus  is  derived  from  both 
spinal  and  sympathetic  nerves,  the  spinal  from  the  fourth  sacral  and 
pudic  nerves,  the  sympathetic  from  the  inferior  hypogastric  plexus. 

Ligaments.  The  round  ligaments  are  two  flattened  cords,  four 
inches  long,  one  on  each  side,  extending  from  the  upper  angle  of  the 
uterus  upward,  outward,  and  forward,  through  the  inguinal  canals 
to  the  upper  part  of  the  labium  majus.  The  broad  ligaments  are 
formed  by  a  double  layer  of  peritonaeum  continuous  with  the 
anterior  and  posterior  coverings  of  the  uterus  at  either  edge.  They 
run  from  the  uterus  to  the  corresponding  side  wall  of  the  pelvis  in 
front  of  the  sacro-iliac  joint.  The  idero-sacral  ligaments  are  two 
bands  covered  with  peritonaeum,  passing  posteriorly  from  the  upper 
third  of  the  cervix  to  the  third  sacral  vertebra;  in  each  ligament 
there  is  a  fiat  band  of  muscle  running  along  its  outer  part.  The 
utero-vesical  ligaments  are  two  folds  of  peritonaeum  passing  from 
the  sides  of  the  uterus  to  the  bladder  and  the  internal  boundaries 
of  the  utero-vesical  pouch. 

Anomalies  of  Uterus  and  Vagina. — Faulty  or  arrested  develop- 
ment of  Miiller's  ducts  may  cause  anomalies  of  the  uterus,  the 
vagina,  or  of  both.  The  chief  varieties  are :  tderus  unicornis, 
uterus  bicornis,  the  uterus  being  bifid  at  upper  extremity  only; 
complete  double  tderus  with  one  vagina ;  complete  double  uterus  and 
vagina;  uterus  masculinus 

Oviducts  or  Fallopian  Tubes. — These  are  tubes  situated  one  on 
each  side  of  the  uterus  in  upper  border  of  the  broad  ligament. 
Each  tube  is  4+  inches  (11  cm.)  long  and  consists  of  the  narrow 
isthmus  near  the  uterus,  the  ampulla  or  wider  portion  near  the 


12 


ANATOMY 


ovary,  and  the  infundibulum  or  fimbriated  extremity.  The  fim- 
briae run  from  the  fringed  edge  of  the  ampulla.  One  fimbria  is 
attached  to  the  ovary  and  is  called  the  tubo-ovarian  ligament, 
or  the  fimbria  ovarica.  A  narrow  strip  of  the  lower  surface  of  the 
tube  is  in  contact  with  the  connective  tissue  between  the  two 
layers  of  the  broad  hgament.  Each  has  three  coats :  external  or 
peritoneal;  middle  or  muscular;  internal  or  mucous  lined  with 
columnar  ciliated  epithelium. 

The  Parovarium  or  Organ  of  Rosemnuller. — This  is  the  homo- 
logue  of  the  epididymis  in  the  male.  It  is  situated  in  the  broad 
ligament,  on  either  side,  between  the  ovary  and  the  ampulla  of  the 
Fallopian  tube,  and  is  lined  by  cihated  epithelium.     It  is  composed 


Fig.  14. — Longitudinal  Folds  of  Tubal  Mucosa  (Williams) 


of  tubules  which  converge  toward  the  ovary  and  are  connected 
by  a  longitudinal  tube,  the  duct  of  Gartner.  This  duct  is  a  rem- 
nant of  the  Wolffian  duct,  and  is  the  homologue  of  the  vas  deferens. 
This  organ  is  originally  the  paroophoron  plus  the  epoophoron, 
which  are  respectively  the  renal  and  sexual  portions  of  the  meso- 
nephros  in  the  female.  These  atrophy  in  development  and  the  re- 
mains are  called  parovarium. 

Ovaries. — These  are  two  in  number,  very  rarely  three,  are  sit- 
uated behind  the  broad  hgament  on  each  side  at  the  level  of  the 
pelvic  brim  about  midway  between  the  psoas  muscle  and  the 
uterus.  The  folds  of  the  broad  hgament  form  a  sort  of  mesentery, 
the  mesovarium  attached  to  the  hilum  of  the  ovary.  Each  ovary 
is  attached  to  the  fimbriated  extremity  of  the  Fallopian  tube  by 
one  fimbria,  and  is  connected  with  the  uterus  by  the  hgament  of 
the  ovary.     The  ovaries  are  almond-shaped,  and  H  inches  (3  cm.) 


THE  FEMALE  REPRODUCTIVE  ORGANS     13 

long,  I  inch  (2  cm.)  wide,  ^  i^^'^i  (^  cm.)  thick,  each  weighing  one 
to  two  drams  (6  gm.).  Tlioy  are  covered  by  a  layer  of  cyhndrical 
cells  (germ  epithelium)  unhke  the  squamous  epithelium  of  the 
peritonaeum. 

The  outer  surface  is  pale,  looking  like  a  mucous  surface  and 
not  like  the  glistening  peritoneum.  "  The  white  line  of  Farre"  is 
the  raised  white  line  of  tissue  at  the  junction  of  the  ovary  and  the 
broad  ligament,  marking  the  junction  of  the  peritonai'um  and  the 
layer  of  germ  e]:)it helium  covering  the  ovary. 

In  the  ovary  there  are  two  portions  or  zones.  A  medullary 
portion  or  zona  vasculosa,  consisting  of  connective  tissue,  un- 
striped  muscle,  and  numerous  blood-vessels  and  lymphatics.  A 
cortical,    or    parenchymatous    zone,         ^ 

by  the  naked  eye.     They  have  a  cap-  ^^^  i5.-Human  Owm 

sule  of  three  layers  :  the  external,  or  (Reichert).     x  6. 

tunica   fibrosa,  consisting  of    COnnec-         e.a.,  embryonic  area;  v.,  villi. 

tive  tissue  with  vessels ;  the  internal, 

or  tunica  propria,  consisting  of  non-vascular  connective  tissue; 
and  the  membrana  granulosa,  lining  the  tunica  propria.  This  is 
the  most  important  layer  of  the  three,  being  an  epithelial  Uning 
which  is  made  up  of  rounded  nucleated  cells  several  layers  deep. 
At  points  over  this  membrane  the  cells  are  heaped  up  in  a  mass 
(discus  proligerus)  surrounding  the  female  sexual  cell,  the  ovum. 
The  ovum  or  ovule  is  a  highly  organized  cell  about  2i)i)  inch 
(.01  mm.)  in  diameter,  and  has  a  structure  peculiar  to  itself.  There 
is  a  tough,  elastic,  and  transparent  investing  membrane,  called  the 
vitelline  membrane  or  zona  pellucida.  This  surrounds  a  semifluid 
protoplasmic  mass,  the  Tjolk  or  vitellus.  In  this  mass,  correspond- 
ing to  the  nucleus  of  an  ordinary  cell,  there  is  an  oval  body  con- 
taining a  few  granules,  but  more  transparent  than  the  rest  of  the 
yolk,  which  is  called  the  germinal  vesicle.  Among  these  granules  is 
a  spot,  corresponding  to  the  nucleolus  of  a  cell — the  germinal  spot. 


14  A^TATOMY 


THE  MAMM^  OR  MAMMARY  GLANDS 

These  are  two  large  milk  glands,  situated  one  on  either  side, 
between  the  two  layers  of  the  superficial  fascia  upon  the  pectoralis 
major  muscle  over  a  space  corresponding  to  that  between  the  third 
and  seventh  rib.  Quite  a  third  of  each  gland  hes  upon  the  serra- 
tus  magnus  muscle  and  beyond  thfe  anterior  border  of  the  axilla. 
The  axillary  lobe  reaches  upward  in  the  axilla,  to  the  upper  bor- 
der of  the  third  rib,  where  it  is  in  contact  with  the  central  set  of 
the  lymphatic  glands. 

Each  gland  presents  three  zones — peripheral,  middle,  and  cen- 
tral—known as  Charpentier's  zones.  The  peripheral  one  is  the  larg- 
est ;  it  has  a  smooth  white  surface,  through  which  the  underlying 
veins  are  easily  visible.  The  middle  zone,  or  areola,  is  about  ^ 
inch  wide ;  its  color  is  pale  rose  in  virgins,  slightly  darker  in 
brunettes,  but  this  color  becomes  much  darker  during  pregnancy. 
It  contains  many  sebaceous  glands,  and  in  addition  twelve  to 
twenty  papular  or  tubercle-like  projections  called  the  tubercles  of 
Montgomery.  The  central  zone  is  occupied  by  the  nipple,  which 
is  nearly  |  inch  high  and  ^  inch  in  diameter.  Its  surface  is 
slightly  roughened  from  the  presence  of  papillae.  The  nipple 
may  be  retracted ;  this  is  seen  especially  in  mahgnant  disease  of 
the  breast. 

The  gland  itself  is  racemose,  there  being  from  fifteen  to  twenty 
lobes,  each  composed  of  lobules,  which  are  again  divided  into  acini 
or  cul-de-sacs.  The  ducts  of  the  lobules  drain  the  acini  and  unite 
to  form  the  excretory  ducts  of  the  lobes — galactophorous  or  milk 
ducts.  These  end  in  the  lactiferous  sinuses  in  the  nipple.  In  ad- 
dition to  the  glandular  substance  each  contains  transverse  and 
longitudinal  muscles  and  some  connective  tissue.  Beneath  the 
peripheral  portion  there  is  considerable  fat.  The  skin  covering 
the  gland  has  developed  in  it  sebaceous  glands  and  hair  follicles. 


CHAPTER  II 
PHYSIOLOGY 

Ovulation. — The  chief  functions  of  the  ovary  are  to  supply  the 
ovum  and  to  expel  it,  when  ready  for  impregnation,  into  the  Fallo- 
pian tubes.  In  the  human  female  this  expulsion  is  closely  related 
to  menstruation,  occurring  usually  before  the  commencement  of 
the  period  and  immediately  following  the  rupture  of  the  follicle. 
Graafian  follicles  develop  very  early,  but  only  begin  to  mature  at 
puberty,  and  continue  to  mature  throughout  the  entire  child-bear- 
ing period.  Ovulation,  however,  ceases  during  the  periods  of  ges- 
tation and  lactation.  When  ovulation  is  about  to  occur  one  of 
the  follicles  becomes  especially  developed,  grows  and  becomes 
congested  and  distended  with  fluid.  The  coverings  of  the  ovary 
over  the  follicle  are  thinned  by  pressure  and  rupture  occurs.  The 
ovule,  surrounded  by  some  cells  of  the  membrana  granulosa  escapes 
into  the  fimbriated  extremity  of  the  Fallopian  tube,  which  grasps 
the  ovary  over  the  site  of  rupture  and  is  propelled  along  the  tube 
by  the  cilia  and  the  muscular  contraction  of  the  tube  walls. 

The  follicle,  after  its  rupture,  and  the  escape  of  the  ovum,  is 
called  the  corpus  luteum.  Of  these  there  are  two  kinds,  the  true 
and  so-called  false  corpus  luteum.  The  true  corpus  luteum  is  the 
corpus  luteum  of  pregnancy.  The  follicle  continues  to  grow  until 
the  third  or  fourth  month  and  projects  on  the  surface  of  the  ovary, 
the  size  being  1  inch  by  h  inch  (2.5  by  1  cm.).  After  this  it  com- 
mences gradually  to  decrease  and  disappears  about  the  end  of 
gestation.  The  false  corpus  luteum  is  formed  when  impregnation 
of  the  ovum  does  not  occur.  After  the  escape  of  the  ovum  the 
edges  of  the  rent  in  the  follicle  adhere  and  the  folHcle  shrinks.  The 
inner  layer  becomes  wrinkled  and  begins  to  show  yellow  folds, 
which  enlarge  and  adhere,  filling  the  cavity.  The  yellow  color 
gradually  changes  to  white.  There  is  progressive  diminution  in 
size,  and  in  about  forty  days  disappearance  occurs,  leaving  a 
slight  depression  on  the  surface  of  the  ovary. 

3  15 


16  PHYSIOLOGY 

Menstruation. — This  is  known  by  various  names,  catamenia, 
periods,  monthly  sickness,  courses,  etc.  It  becomes  estabhshed  at 
puberty,  in  temperate  chmates  at  about  fourteen  to  sixteen  years, 
but  it  may  come  on  earher  in  hot  chmates  and  later  in  cold.  It 
occurs  regularly  every  twenty-eight  days  in  the  majority  of  women, 
although  in  some  it  may  be  every  twenty-one.  Its  average  dura- 
tion is  four  to  five  days.  The  quantity  of  blood  lost  varies  from 
2  to  4  ounces  (64—124  gm.) ;  but  this  is  more  or  less  affected 
by  climate  and  modes  of  living;  more  is  lost  by  women  living  in 
hot  climates  or  those  living  an  easy,  luxurious  life.  The  blood  is 
pure,  but  does  not  coagulate  except  w^hen  there  are  large  amounts, 
on  account  of  the  mucus  contained  in  it.  At  first  it  is  dark,  but 
becomes  lighter  in  color.  The  menses  usually  have  a  slight  odor: 
The  blood  is  derived  from  the  mucous  lining  of  the  uterus,  the 
mucous  membrane  being  intensely  congested  at  the  time  of  men- 
struation. The  time  of  the  cessation  of  menstruation  is  uncertain, 
but  generally  occurs  at  the  age  of  forty-five  to  fifty,  frequently 
earlier,  sometimes  later.  After  this  time  Graafian  follicles  no 
longer  mature,  and  the  ovaries  become  shriveled  and  wrinkled  on 
the  surface.  The  Fallopian  tubes  become  atrophied  and  some- 
times obHterated.  The  uterus  decreases  in  size.  This  is  es- 
pecially marked  in  the  cervical  portion.  Its  projection  into  the 
vagina  disappears,  and  the  orifice  of  the  os  uteri  in  old  women  is 
often  found  to  be  flush  with  the  roof  of  the  vagina. 

Theory  of  Menstruation. — Some  say  that  menstruation  depends 
on  ovulation.  There  is  certainly  a  close  connection  between  ovula- 
tion and  menstruation.  Others  say  that  ovulation  does  not  de- 
termine menstruation,  which  is  probably  correct.  It  is  likely  that 
both  ovulation  and  menstruation  depend  on  a  common  cause,  the 
periodic  nervous  excitation  and  congestion  due  to  an  impulse  from 
the  sympathetic  system  (Hirst).  They  generally  occur  together, 
but  there  are  many  exceptions  and  either  may  occur  without 
the  other. 

Conception  and  Generation. — Conception  means  the  union  of 
two  living  elements — one  male,  the  other  female — and  is  effected 
by  union  of  the  spermatozoon  with  the  ovum.  This  union  is  called 
fecundation  or  impregnation.  It  is  simple  or  single  if  one  ovum 
has  been  impregnated,  multiple  if  two  or  more  ova  have  been 
impregnated. 

The  spermatozoa  are  ejaculated  in  the  semen,  a  viscid,  opales- 


CONCEPTION    AND    GENEEATION  17 

cent  fluid.  Each  has  a  head,  body,  and  tail  and  possesses  a  power 
of  movement  similar  to  that  of  an  eel  in  water.  This  movement 
is  very  important  in  conception.  They  may  live  for  many  days 
in  the  female  genital  tract. 

Impregnation  takes  place  probably  in  the  Fallopian  tubes  near 
the  pavihon.  The  spermatozoa  move  up  through  the  uterus  and 
tubes  to  meet  the  ovum.  Even  when  deposited  at  the  vulva  they 
may  pass  up  through  the  vagina,  cervical  canal,  and  uterus,  into 
the  Fallopian  tubes.  This  is  brought  about  partly  by  their  own 
vibratory  motion,  and  partly  by  their  being  sucked  up  by  the 
uterus. 


CHAPTER  III 
THE  EMBRYO   AND  FCETUS 

Early  Changes  in  Ovum. — After  impregnation  segmentation  of 
the  yolk  begins.  The  yolk-mass  becomes  divided  up  into  first 
two,  then  four,  eight,  sixteen,  and  so  on,  parts,  each  of  which  is  a 
nucleated  cell.  When  segmentation  is  completed  some  of  the  cells 
arrange  themselves  in  a  layer  around  the  periphery  of  the  ovum, 
thus  forming  a  membrane  enclosing  the  rest  of  the  cells.  The 
enclosed  cells  adhere  in  a  mass  to  one  spot  on  the  inner  surface  of 
the  enclosing  layer  and  thus  form  the  embryonic  area.  At  this 
spot  the  embryo  commences  to  be  formed.  The  outer  layer  is 
called  the  epiblast;  the  inner  layer  of  adherent  cells  the  hypo- 
blast. A  middle  layer  grows  from  the  angle  of  their  union  and  is 
called  the  mesoblast.  At  the  central  part  of  the  ovum  a  quantity 
of  fluid  appears. 

The  ovum  now  has  four  layers  surrounding  the  cavity  contain- 
ing the  fluid,  which  are  from  without  inward — the  zona  pellu- 
cida;  the  epiblast;  the  mesoblast;  the  hypoblast.  The  three  in- 
ner layers  are  fused  together  in  the  embryonic  area.  The  meso- 
blast splits  into  two  layers,  one  of  which  is  united  to  the  epiblast, 
forming  the  somatopleure ;  the  other  is  united  to  the  hypoblast, 
forming  the  splanchnopleure.  The  embryo  now  commences  to 
be  formed  and  sinks  toward  the  center  of  the  ovum  and  develop- 
ment into  the  foetus  is  commenced.  During  this  development 
from  embryo  into  foetus  several  very  important  structures  are 
formed. 

Decidua. — After  impregnation  the  uterine  mucous  membrane 
becomes  congested,  convoluted,  and  hypertrophied ;  it  is  called 
the  decidua  vera.  When  the  ovum  enters  the  uterus  it  lodges  be- 
tween two  folds  of  the  decidua  vera.  The  decidua  grows  around 
the  ovum,  forming  the  decidua  reflexa.  For  a  time  there  is  a 
space  between  the  decidua  reflexa  and  decidua  vera  which  con- 
tains a  mucous  fluid.     At  the  end  of  three  months  this  space  it 

18 


DECIDUA 


19 


obliterated  by  the  union  of  the  two  layers.     That  portion  of  de- 
cidua  vera  on  whirh  tho  ovum  rests  is  called  the  decidua  serotina. 


Fig.  16. — Uterus  lined  by  Decidua,  containing  Seven-  to  Eight-Days' 
Ovum  (Leopold),      x  1. 


There  are  three  membranes  surrounding  the  embryo  from 
within  outward :  the  amnion ;  the  chorion ;  the  decidua  refiexa  ; 
and  serotina. 

The  amnion  is  essentially  a  foetal  membrane,  formed  from  a 
fold  of  the  somatopleure,  principally  from  the  head  to  the  tail  ends, 
but  also  from  the  sides.  Two  layers  are  formed:  (1)  the  internal 
layer  of  amnion,  or  true  amnion,  which 
surrounds  the  foetus,  but  becomes  grad- 
ually distended  with  amniotic  fluid ;  (2) 
the  external  layer  of  amnion,  or  false 
amnion,  or  prechorion,  which  unites  with 
the  allantoic  structures,  forming  the  cho- 
rion. 

The  chorion  is  made  up  of  two  layers, 
the  prechorion  or  false  amnion  and  the 
allantois.  The  allantois  is  a  continuation 
of  the  intestinal  mucous  membrane, 
mostly  solid,  although  there  is  a  small 
hollow  in  the  stalk.     It  spreads  inside  the 


O^ 


Fig.  17. 


Fig.  is. 


Figs.  17,  18. — Diagrams 
SHOWING  Formation 
OF  Decidua  Reflex.^ 
(Coste). 


20 


THE    EMBEYO    AND    FCETUS 


hollow  amniotic  pouch  and  finally  surrounds  the  foetus.  The  por- 
tion of  the  allantois  within  the  abdominal  walls  becomes  the 
apical  part  of  the  bladder  and  the  urachus.  The  portion  out- 
side the  abdominal  plates  forms  the  vasculosa  or  inner  layer  of 
the  chorion  and  part  of  the  umbilical  cord.  The  vitelline  mem- 
brane is  so  greatly  thinned  by  enlargement  of  the  ovum  that  it 
practically  disappears.  The  chorion  shortly  becomes  covered  with 
projecting  villi.  Each  villus  receives  a  capillary  vascular  loop 
from  the  vessels  of  the  allantois.     These  grow  especially  in  that 


Fig. 


19. — Diagram  showing  Transverse  Section  through  Mammalian 
Embryo,  showing  Formation  of  Amnion  (Williams). 


part  which  is  concerned  in  the  formation  of  the  placenta.  The  villi 
after  a  time  disappear  from  the  remaining  portion  of  the  chorion. 

There  is  therefore  from  within  outward  the  inner  layer  of.  the 
amnion  containing  the  liquor  amnii,  in  which  the  foetus  floats. 
Outside  this  there  is  the  allantois  united  with  the  outer  layer  of 
the  amnion  forming  the  chorion.  After  a  time  the  chorion  blends 
with  the  decidua  reflexa  and  the  reflexa  with  the  vera ;  so  that  at 
birth  this  outer  layer  is  formed  of  three,  the  chorion,  the  decidua 
reflexa,  and  decidua  vera;  the  inner  layer  is  formed  of  the  true 
amnion  alone. 

Placenta. — This  in  the  human  female  is  a  circular  mass  attached 
to  the  internal  surface  of  the  uterus,  generally  at  or  near  the  fundus. 


PLACENTA 


21 


E.       "RT  \ 


Fig.  20. — Seventeen-Days'  Pregnant  Uterus.      x  1.      (Anatomical  MuseTim, 
Johns  Hopkins  University.)      Embryo  drawn  relatively  too  large  (Williams). 

D.R.,  deeidua  reflexa;  D.S.,  decidua  serotina;    D.V.,  decidua  vera;  E.,  embryo; 
O.L.,  ovarian  ligament;  R.L.,  round  ligament. 

It  is  developed  in  the  decidua  vera.  Its  average  diameter  is  from 
6  to  9  inches;  it  weighs  from  1  to  1^  pounds. 

Its  functions  are:  (1)  respiration,  (2)  nutrition,  and  (3)  ex- 
cretion. 

1.  Respiration.  It  acts  as  the  lung,  or  rather  the  gill,  in  oxy- 
genating the  foetal  blood  by  the  interchange  of  gases  which  takes 


22 


THE    EMBKYO    AND    FCETUS 


place  between  the  foetal  and  maternal  blood.  The  blood  from  the 
foetus,  darkened  with  carbon-diox  de,  passes  through  the  umbil- 
ical arteries  to  the  placenta,  and  the  oxygenated  blood  returns 
through  the  umbilical  vein  of  the  ^oetus. 

2.  Nutrition.  The  epithelial  cells  of  the  chorionic  villi  absorb 
nutriment  from  the  foetal  blood  and  in  doing  so  show  a  selective 
power. 

3.  Excretion.  The  epithelial  cells  of  the  chorionic  villi  also 
excrete  waste  products  from  the  foetus. 

The  foetal  membranes  cover  the  foetal  surface  of  the  placenta 
and  pass  from  its  edges  to  Hne  the  portion  of  the  internal  surface 
of  the  uterus  not  including  the  decidua  serotina,  but  do  not  form 

a  sheath  to  the  cord, 
as  formerly  s  u  p  - 
posed.  The  cord  is 
generally  attached  at 
or  near  the  center  of 
the  placenta.  The 
maternal  surface  is 
rough  and  divided 
by  numerous  sulci. 
After  expulsion  of 
the  placenta,  this 
surface  is  covered  by 
the  superficial  or  cel- 

FiG.  21.— Diagram  of  Placenta.  lular     layer     of     the 

decidua  serotina, 
while  its  deeper  layer  remains  attached  to  the  wall  of  the  uterus. 
Numerous  small  openings  are  found  on  it  which  are  the  apertures 
of  veins  torn  off  from  the  uterus. 

Structure  and  Formation  of  the  Placenta.  It  is  made  up  of  two 
portions :  a  foetal  portion  containing  the  hypertrophied  villi  of 
the  chorion  with  their  contained  vessels,  and  a  maternal  portion 
containing  the  decidua  serotina  with  its  contained  vessels.  These 
two  portions  are  intimately  blended,  forming  the  placenta  which 
is  expelled  after  the  birth  of  the  child. 

It  is  formed  in  the  following  manner :  The  villi  of  the  chorion 
penetrate  the  decidua  serotina,  forming  large  sinuses  into  which 
the  villi  enter.  The  intervening  structures  between  the  two  sets 
pf  vessels  are,  to  a  large  extent,  but  not  altogether,   absorbed. 


APPEARANCE    OF    THE    F(ETUS 


23 


There  is  never  any  direct  communication  between  these  two  sets 
of  vessels — i.  c.,  the  maternal  and  foetal  blood  never  mix.  Be- 
tween the  maternal  blood,  coming  directly  from  the  lungs  and 
fully  oxygenated,  and  that  of  the  foetus  which  is  carbonized,  there 
is  only  a  thin  layer  of  tissue,  composed  of  (a)  the  epithelium  cover- 
ing the  surface  of  the  villus,  (b)  the  tissue  of  the  villus  itself,  (c) 
the  wall  of  the  small  branch  of  artery  in  the  villus. 

The  epithelium  covering  the  surface  of  the  villi  is  partially, 
if  not  wholly,  absorbed.  Through  this  thin  layer,  or  diaphragm, 
the  two  currents  of  blood  interchange 
their  gases  and  soluble  substances  by 
diffusion  and  osmosis.  The  carbon-di- 
oxide gas  from  the  foetus  passes  into  the 
maternal  blood,  while  oxygen  passes 
from  the  maternal  blood  into  the  foetus. 

Umbilical  Cord. — This  is  the  channel 
of  communication  between  the  foetus  and 
the  placenta,  passing  from  the  umbilicus 
to  the  center  of  the  placenta  (generally). 
It  is  generally  18  to  24  inches  (46  to  61 
cm.)  long,  but  may  be  in  exceptional 
cases  5  to  60  inches  (13  to  152  cm.).  At 
birth  it  is  formed  of  an  external  layer 
derived  from  the  skin  of  the  embryo, 
two  umbilical  arteries,  an  umbilical  vein, 
and  the  remains  of  the  allantois  embed- 
ded   in   a   gelatinous    substance    called 

' 'Wharton's  jelly."  Early  in  foetal  Hfe  the  vessels  are  straight,  but 
soon  become  much  twisted.  The  arteries  are  external  to  the  vein 
and  have  no  branches;  the  vein  has  no  valves.  The  pedicle  of 
the  umbilical  vesicle,  which  is  present  early  in  pregnancy,  disap- 
pears. Sometimes  a  funnel-shaped  diverticulum  of  the  coelome 
(a  diverticulum  of  the  abdominal  peritonaeum)  persists  into  which 
coils  of  the  intestine  may  pass  and  be  strangulated  during  the 
ligature  of  the  cord. 

Appearance  of  the  Foetus  at  Different  Months. — The  following 
short  description  will  indicate  the  development  of  the  foetus. 

At  the  end  of  the  first  month  the  ovum  is  about  |  inch  (2  cm.) 
long,  being  about  the  size  of  a  pigeon's  egg.  The  embryo  is 
about  4-  inch  (1  cm.)  long.     The  umbilical  vesicle  is  smaller  th^D 


Fig.  22. — Section  through 
Young  Umbilical,  Cord 
(Minot). 

A.,  artery;  AIL,  allantois; 
U.S.,  stalk  of  umbilical 
vesicle;  V.,  vein. 


24 


THE    EMBEYO    AND    FCETUS 


the  embryo.     The  amnion  is  separated  by  a  small  interval  from 
the  chorion. 

At  the  end  of  the  second  month  the  ovum  is  2  inches  (5  cm.) 
long,  being  about  the  size  of  a  hen's  egg.     The  amnion  is  distended 


Fig.  23. 


Fig.  24. 


Fig.  25. 


Fig.  26. 


Figs.  23-26. — Embryos  from  Fourth  and  Fifth  Weeks  (His),      x  2. 


and  is  in  contact  with  the  chorion.     The  villi  of  the  chorion  are 
more  developed.     The  cord  is  straight. 

At  the  end  of  the  third  month  the  ovum  is  4  inches  (10  cm.) 
long.     The  placenta  is  formed.     The  villi  in  the  other  portions  of 


Fig.  27.  Fig.  28.  Fig.  29. 

Figs.  27-29. — Embryos  from  Second  Month  (His).      x2. 


APPEARANCE    OF    THE    FCETUS  25 

the  chorion  have  nearly  disappeared.     The  cord  is  longer  and 
slightly  twisted.     The  limbs  anfl  head  have  developed. 

At  the  end  of  the  fourth  month  the  foetus  is  6  inches  (15  cm.) 
long  and  weighs  3  ounces  (93  gm.);  the  sex  is  distinguishable. 


Fig.  30.      Fig.  31.  Fig.  32.  Fig.  33.  Fig.  34 

Figs.  30-34. — Composite  of  Fcetuses   at  Ages  of  Two,  Three,  Five,  Seven 
AND  Nine  Months  respectively. 

At  the  end  of  the  fifth  month  the  foetus  is  9  inches  (23  cm.) 
long  and  weighs  11  ounces  (342  gm.)  There  is  hair  on  the  head 
and  lanugo  or  down  covers  the  body.  The  foetus  when  born  may 
move,  and  such  movements  continue  for  some  hours. 


26 


THE    EMBKYO    AND    FCETUS 


At  the  end  of  the  sixth  month  the  foetus  is  12  inches  (30  cm.) 
long  and  weighs  24  ounces  (746  gm.)  The  eyebrows  and  lashes 
are  beginning  to  form.  The  foetus  born  at  this  time  may 
breathe  feebly,  but  soon  dies.  A  little  meconium  exists  in  large 
intestine. 

At  the  end  of  the  seventh  month  the  foetus  is  15  inches  (38  cm.) 
long  and  weighs  45  ounces  (1,400  gm.).  The  eyelids  are  open. 
The  child  is  viable.  The  face  is  wrinkled.  One  testicle  generally 
is  in  the  scrotum.  The  nails  do  not  reach  the  tips  of  the  fingers. 
The  membrana  pupillaris  is  absent. 

At  the  end  of  the  eighth  month  the  foetus  is  17  inches  (43  cm.) 
long  and  weighs  4^  pounds  (2,200  gm.).  The  face  is  less  wrinkled, 
owing  to  a  greater  deposit  of  subcutaneous  fat.  The  foetus  may 
live. 

At  the  end  of  the  ninth  month  (full  term),  the  foetus  is  21 
inches  (53  cm.)  long  and  weighs  7  pounds  (3,470  gm.).  The  finger 
nails  project  beyond  the  tips  of  the  fingers.     It  is  covered  with  the 


Fig.  35. — Child's  Head  at  Term. 


(American  Text-Book.) 


vernix  caseosa,  a  greasy  material  formed  of  epithelial  scales  and  the 
secretion  of  the  sebaceous  glands. 

The  foetus  at  full  term  presents  some  very  important  charac- 
teristics, differing  in  some  respects  from  the  adult. 


THE    FCETAL    HEAD 


27 


The  Foetal  Head. — The  bones  of  the  skull,  particularly  at  the 
vertex,  are  but  loosely  joined  together  by  membrane  allowing  the 
head  to  be  molded,  to  a  certain  extent,  in  passing  through  the 
mother's  pelvis.  The  su- 
tures are  merely  mem-  Ucciput 
branous  septa  between 
the  separate  bones.  They 
are  as  follows :  the  sagit- 
tal suture  unites  the  two 
parietal  bones;  the  fron- 
tal unites  the  two  por- 
tions of  the  frontal  bone 
and  is  continuous  with 
the  sagittal  suture;  the 
coronal  unites  the  frontal 
and  the  parietal  bones 
and  extends  from  the 
squamous  portion  of  the 
temporal  bone  across  the 
head  ;  the  lambdoidal 
unites  the  occipital  and 
the  parietal  bones. 

Fontanelles.  In  two 
places  there  are  membra- 
nous interspaces  where  the 
sutures  join  each  other; 
these  are  called  fonta- 
nelles. One,  the  anterior  fontanelle,  is  larger  and  lozenge-shaped ; 
it  is  formed  at  the  junction  of  the  frontal,  sagittal,  and  coronal 
sutures.  The  other,  the  posterior  fontanelle,  is  smaller  and  tri- 
angular; it  is  formed  at  the  junction  of  the  sagittal  suture  with 
the  two  arms  of  the  lambdoidal  suture. 

Diameters.  A  knowledge  of  the  diameters  of  the  foetal  skull 
is  of  great  importance.  They  are  as  follows :  The  occipito-mental, 
from  the  occipital  protuberance  to  the  point  of  the  chin,  5^  to  5j 
inches  (13  cm.);  the  occipito-frontal,  from  the  occipital  protuber- 
ance to  the  center  of  the  forehead,  4 J  inches  to  5  inches  (12  cm.) ; 
the  suhoccipito-bregmatic,  from  a  point  midway  betw^een  the  oc- 
cipital protuberance  and  the  margin  of  the  foramen  magnum  to 
the  center  of  the  anterior  fontanelle,  4  inches  (10  cm.) ;  the  cervico- 


FiG.  36. — Child's  Head  at  Term,      x  f . 
(American  Text-Book.) 


28  THE    EMBEYO    AND    FCETUS 

hregmatic,  from  the  anterior  margin  of  the  foramen  magnum  to 
the  center  of  the  anterior  fontanelle,  4  inches  (10  cm.);  the  hi- 
parietal  or  transverse,  between  the  parietal  protuberances,  4  inches 
(10  cm.) ;  the  fronto-mental,  between  the  apex  of  the  forehead  and 
chin,  3 J  inches  (9  cm.).  These  diameters  may  be  altered  by 
compression  and  molding  during  labor. 

Foetal  Circulation. — The  chief  difference  between  the  course  of 
the  blood  in  the  foetus  and  that  in  the  adult  is  that  in  the  former 
there  is  no  pulmonary  circulation.  The  umbilical  vein,  bringing 
blood  from  the  placenta  to  the  foetus,  after  entering  the  umbilicus 
sends  two  branches  to  the  liver  joining  the  divisions  of  the  portal 
vein,  while  the  main  trunk,  called  the  ductus  venosus,  empties 
into  the  inferior  vena  cava.  The  blood  from  the  liver  also  empties 
through  the  hepatic  vein  into  the  inferior  vena  cava.  The  pure 
blood  from  the  placenta  is  thus  mixed  with  the  blood  coming 
through  the  inferior  vena  caVa  from  the  lower  extremities. 

The  inferior  vena  cava  empties  the  blood  into  the  right  auricle. 
From  the  right  auricle  the  blood  is  directed  by  the  Eustachian  valve 
through  the  foramen  ovale  into  the  left  auricle; — from  the  left 
auricle  into  the  left  ventricle;  from  the  left  ventricle  into  the  aorta. 

The  greater  portion  of  the  blood  passes  through  the  branches  of 
the  aortic  arch  to  the  head  and  upper  extremities.  From  these  the 
blood  returns  by  the  descending  vena  cava  to  the  right  auricle; 
from  the  right  auricle  to  the  beginning  of  the  pulmonary  arteries ; 
thence  into  the  ductus  arteriosus;  thence  into  the  descending 
aorta;  thence  a  portion  into  the  lower  extremity  which  returns 
by  the  ascending  vena  cava;  and  a  larger  portion  passes  along 
the  umbilical  arteries  to  the  placenta. 

Changes  after  Birth. — The  current  through  the  umbilical  ves- 
sels ceases,  the  portion  of  cord  retained  drying  up  and  falling  off; 
the  umbilical  arteries  inside  the  abdomen,  that  is,  the  foetal  hypo- 
gastric arteries,  become  permanent  in  a  part  of  their  course, 
constituting  the  superior  vesical  arteries;  the  ductus  venosus  and 
the  ductus  arteriosus  shrivel  into  fibrous  cords ;  the  foramen  ovale 
closes ;  the  lungs  expand ;  the  blood  which  formerly  went  through 
the  ductus  arteriosus  now  passes  through  the  pulmonary  arteries 
to  the  lungs;  the  blood  from  the  lungs  returns  by  the  pulmonary 
veins  to  the  left  auricle;  from  the  left  auricle  it  passes  into  the 
left  ventricle;  from  the  left  ventricle  it  passes  into  the  aorta  and 
is  distributed  to  the  head,  trunk,  and  extremities. 


NERVOUS    SYSTEM  29 

Foetal  Liver  and  its  Functions. — It  is  large  proportionately,  and 
assumes  its  characteristic  structure  and  secretes  bile  about  the 
fifth  month;  it  helps  to  form  sugar,  which  is  abundant  in  the 
foetus.  The  bile  is  partly  collected  in  the  gall-bladder  and  sub- 
sequently passes  into  the  intestinal  canal.  Here  it  mixes  with  the 
intestinal  mucous  secretions,  forming  the  meconium — a  thick 
tenacious  greenish  substance  which  is  voided  in  considerable  quan- 
tities soon  after  birth. 

Urine. — A  certain  amount  is  formed  during  intrauterine  life, 
some  of  which  may  be  voided  into  the  amniotic  cavity.  (This 
is  denied  by  some.) 

Nervous  System. — The  nervous  system  is  developed  to  some 
extent,  perhaps  sufficiently  to  allow  reflex  action.  The  gray  mat- 
ter of  the  brain  is  quite  rudimentary  in  new-born  babes. 


CHAPTER  IV 

PREGNANCY 

FCETUS  IN  UTERO 

Relations. — The  following  terms  are  used  in  connection  with 
the  relations  of  the  foetus  in  the  uterus:  attitude,  position,  lie, 
presentation. 

Attitude  refers  to  the  relations  of  different  parts  of  the  foetus  to 
each  other. 

Position  refers  to  the  relation  of  a  given  surface  of  the  foetus  to 
the  anterior,  lateral,  or  posterior  aspects  of  the  mother. 

Lie  refers  to  the  relation  of  the  long  axis  of  the  child  to  that  of 
the  mother. 

Presentation  refers  to  the  part  of  the  child  felt  most  prominently 
in  vaginal  examination. 

There  is  a  certain  confusion  about  the  two  terms,  lie  and  pre- 
sentation. For  instance,  when  the  head  is  downward  we  are  said 
by  many  to  have  a  head  presentation.  This  ought,  in  the  opinion 
of  some,  to  be  called  a  head  lie.  The  term  head  presentation  is, 
however,  more  commonly  used.  Presentation,  strictly  speaking, 
means  the  part  of  the  child  which  is  first  touched  by  the  examin- 
ing finger  while  it  is  passing  through  the  parturient  canal.  As 
expressed  by  Matthews  Duncan,  the  term  presentation  means  that 
point  on  the  surface  of  the  child's  head  through  which  the  axis  of 
the  fully  developed  pelvic  canal  passes,  or,  as  it  is  expressed  more 
simply  by  Tyler  Smith,  the  part  which  is  felt  most  prominently 
within  the  circle  of  the  os  uteri,  the  vagina,  and  the  ostium  vaginae 
in  the  successive  stages  of  labor. 

CHANGES  IN  THE  MATERNAL  ORGANISM 

Size  of  Uterus. — The  uterus  is  greatly  increased  in  size.     It 

increases  from  1  ounce  (31  gm.)  in  weight  and  2^  inches  (6  cm.) 

in  length  to  24  ounces  (746  gm.)  in  weight  and  12  inches  (30  cm.) 

in  length.     Before  the  third  month  the  enlargement  is  chiefly  in 

30 


CHANGES  IN  THE  MATERNAL  ORGANISM   31 


the  lateral  direction.  After  the  third  month  it  is  more  in  a 
vertical  direction.  At  the  end  of  the  third  month  the  fundus 
uteri  is  on  a  level  with  the  pelvic  brim.  At  the  end  of  the  fourth 
month  it  is  2  inches  (5  cm.)  above  the  symphysis  pul:)is.  At  the 
end  of  the  fifth  month  it  is  half-way  between  the  pubis  and  the 
umbilicus.  At  the  end  of  the  sixth  month  it  is  on  a  level  with  the 
umbilicus.  At  the  end  of  the  seventh  month  it  is  half-way  be- 
tween the  umbilicus  and  the  ensiform  cartilage.  At  the  end  of 
the  eighth  month  it  is  near  the  ensiform 
cartilage.  At  the  end  of  the  ninth  month 
it  sinks  a  little  in  the  abdomen  (about 
the  last  three  weeks  in  primipara  and 
the  last  week  in  multiparae).     (Fig.  48.) 

The  uterine  w^alls  become  hypertro- 
phied,  but,  at  the  same  time,  somewhat 
softened.  The  enlargement  takes  place 
chiefly  in  the  body  of  the  uterus,  while 
the  cervix  is  very  httle,  if  at  all,  enlarged. 
The  increase  in  the  size  of  the  uterus 
corresponds  to  some  extent  to  that  of 
the  foetus,  but  such  increase  is  really  a 
growth  and  not  due  to  distention.  In 
fact,  the  uterine  cavity  in  early  preg- 
nancy increases  in  size  faster  than  the 
ovum,  while,  at  the  same  time,  the  walls 
become  thicker.  At  a  later  stage  of 
pregnancy  the  ovum  completely  fills  the  cavity  of  the  uterus, 
although  there  is  but  little  or  no  pressure  produced  upon  it  as 
long  as  the  uterine  walls  remain  relaxed. 

One  of  the  most  remarkable  things  in  this  connection  is  the  fact 
that  in  an  ectopic  gestation  the  uterus  goes  on  increasing  in  size 
up  to  the  fourth  month  or  longer  while  the  fructified  egg  is  grow- 
ing in  the  tube. 

Lower  Uterine  Segment. — This  portion  of  the  uterine  body, 
which  is  situated  immediately  above  the  internal  os,  deserves  care- 
ful consideration.  It  is  thinner  and  less  vascular  than  the  rest  of 
the  body.  There  is  a  well-marked  ring  between  the  lower  and 
upper  segment  of  the  uterus  which  has  received  many  names,  as 
follows :  ring  of  Bandl,  contraction  ring,  retraction  ring,  and  re- 
traction ring  of  Schroeder. 
4 


Fig.  39. — Pregnancy  (Five 
Weeks).  (Tor.  Univ.  Mu- 
seum.) 


32 


PEEG^ANCY 


Cervix. — The  cervical  canal  remains  intact  until  about  the  end 
of  pregnancy.  It  was  formerly  supposed  that  during  the  latter 
part  of  pregnancy  the  internal  os  was  drawn  up  to  a  level  above 

the  symphysis  and  that  the 
part  of  the  cervix  thus 
drawn  up  was  dilated  in 
such  a  way  that  it  became, 
practically,  a  part  of  the 
uterine  cavity  which  con- 
tained the  ovum.  We  now 
believe  that  there  is  no 
enlargement  of  the  internal 
OS  until  labor  has  com- 
menced or  is  about  to  com- 
mence. A  certain  amount 
of  confusion  has  arisen  be- 
cause there  is  an  apparent 
shortening  of  the  cervix. 
The  cervix  is  really  not 
shortened  in  the  ordinary 
sense  of  the  word.  The 
erroneous  impression  that 
such  shortening  exists  is 
probably  due  to  the  fact  (as 
explained  by  Dakin)  that 
the  uterus  passes  down  in 
the  pelvis  until  some  of 
the  weight  rests  on  the  pel- 
vic floor  at  a  spot  on  the 
posterior  vaginal  wall  and 
that  the  cervix  is  thus  compressed.  It  is  usually  bent  so  that  the 
external  os  looks  forward  in  the  axis  of  the  vagina.  The  second 
reason  is  that  there  is  a  downward  bulge  of  the  anterior  uterine 
wall  just  above  the  cervix. 

The  softening  of  the  cervix,  which  occurs  early  in  pregnancy, 
is  due  to  oedema  from  congestion  on  account  of  the  pressure  of  the 
uterus  on  the  veins.  It  generally  begins  about  the  end  of  the 
first  or  early  in  the  second  month  and  can  be  readily  detected  in 
most  cases,  but  especially  in  primiparse.  It  should  be  remembered 
in  this  connection  that  a  similar  condition,  that  of  softening  of  the 


Fig.  40.  —  Pregnancy  Two  Months  Ad- 
vanced, SHOWING  Embryo,  Membranes 
AND  Villi  op  Chorion.  (Tor.  Univ.  Mu- 
seum.) 


CHANGES  IX  THE  MATEEXAL  ORGAXISM   33 


cervix,  may  be  ])r()(luc(Ml  by  the  jjrcsence  of  fibroid  or  otiicr  tumors. 
The  late  Dr.  Goodcll,  of  Philadelphia,  attached  a  good  deal  of 
importance  to  this  sign,  and  said  that  in  the  unimpregnated  uterus 
the  cervix  on  being  touched  by  the  finger  felt  about  as  hard  as 
the  end, of  the  nose,  while  in  the  impregnated  uterus  it  felt  about 
as  soft  as  the  surface  of  the  lips. 

The  cervical  canal  contains  a  plug  wliich  has  been  called  by 
some  the  operculum.  Considerable  interest  is  attached  to  this 
plug,  inasmuch  as  it  forms  a 
barrier  which,  under  ordinary 
circumstances,  prevents  path- 
ogenic germs  from  passing  into 
the  uterine  cavity  during  preg- 
nancy. Reference  is  also  made 
to  the  operculum  in  the  chapter 
on  Puerperal  Infection. 

Broad  Ligaments  and  Peri- 
tonaeum.— As  the  fundus  uteri 
rises  in  the  abdominal  cavity 
the  broad  ligaments  are  carried 
with  it  so  that  the  edge,  instead 
of  being  nearly  horizontal,  after 
a  time  becomes  almost  vertical ; 
at  the  same  time  the  fundus  of 
the  uterus  becomes  much  ele- 
vated above  the  level  of  the  two 
cornua.  About  the  end  of  preg- 
nancy the  tubes  appear  to  join 
the  uterus  about  midway  be- 
tween the  fundus  and  the  inter- 
nal OS  (see  Fig.  84). 

The  peritonaeum  is  probably 
to  some  extent  stripped  from 
the  bladder.  The  central  part 
of  the  lower  portion  of  Doug- 
las's cul-de-sac  does  not  appear 
to  be  raised  during  pregnancy. 

There  is  some  hypertrophy  of  the  round  ligaments  and  also  of  the 
muscle-fiber  in  the  broad  ligaments.  The  increase  in  the  round 
ligaments  is  so  great  that  they  can  often  be  felt  through  the  ab- 


FiG.  41. — Pregnancy  Three  Months, 

SHOWING    FCETUS    BeLOW,  CoRD,  AND 

Placenta  forming  on  Right  Side 
Above.      (Tor.  Univ.  Museum.) 


34 


PEEG^^ANCY 


dominal  walls  at  the  latter  part  of  pregnancy,  the  left  being  more 
readily  felt  on  account  of  dextrorotation  of  the  uterus,  which 
brings  the  left  side  forward.     The  ovaries  are  lifted  slightly  above 

the  pelvic  brim  and  are  brought 
closer  to  the  side  of  the  uterus  on 
account  of  the  growth  of  the  lat- 
ter between  the  layers  of  the 
broad  ligament. 

Decidua. — The  mucosa  dur- 
ing labor  consists  of  three  layers : 
compact,  spongy,  and  deep.  The 
compact  layer  is  superficial  and 
has  decidual  cells  lying  between 
the  glands,  which  are  much  di- 
lated with  epithelium  flattened 
and  degenerated.  The  spongy  or 
middle  layer  has  glands  widely 
dilated  with  spindle  cells  and 
fibers  of  connective  tissue  be- 
tween them.  The  deep  layer  is 
thin  and  dense  and  consists  of 
connective  tissue  containing  blind 
ends  of  glands  whose  epithelium 
is  unchanged.  It  is  closely  at- 
tached to  the  muscular  wall. 

The  separation  of  the  decidua 
at  abortion  or  full-time  parturi- 
tion occurs  through  the  spongy 
layer,  the  dilated  glands  acting 
like  the  row  of  perforations  be- 
tween two  postage  stamps  and 
allowing  separation  to  occur  eas- 
ily.    After  the  separation  of  the 
decidua  the  mucosa  is  renewed, 
and  covered  by  the  epithelium  of  the  blind  ends   of  the  glands 
which  remain  attached  to   the  muscular  wall   (Fothergill).     This 
is  again  referred  to  in  the  chapter  on  Abortion. 

Circulatory  System. — It  was  formerly  supposed  that  the  blood 
in  pregnancy  was  increased  in  quantity  and  also  changed  in  char- 
acter.    It  was  thought  that  it  became  more  watery  and  contained 


Fig.  42. — Five  Months  Peegnancy. 
Placenta  with  Sac  containing 
FcETUs  attached.  (Tor.  Univ.  Mu- 
seum.) 


CHANGES  m  THE  MATERNAL  ORGANISM   35 

more  fibrin   and   white   corpuscles,  and   at   the  same  time  fewer 
red  corpuscles  and  less  albumin. 

It  has  been  clearly  demonstrated,  however,  in  recent  years  that 
no  important  changes  occur  in  the  blood  during  pregnancy.  The 
slight  increase  in  the  number  of  the  white  blood  corpuscles,  or 
leucocytosis,  which  occurs  during  the  last  few  days  of  pregnancy, 
but  especially  during  the  first  week  of  the  puerperium,  is  referred 
to  in  another  chapter.     It  is  also  thought  by  many  recent  observ- 


FiG.  43. — Full  Term  Pregnancy;  Fcetus  in  Sac,  Membranes  partially 
Detached  from  Edge  of  Placenta.     (Tor.  Univ.  Museum.) 


ers  that  the  amount  of  haemoglobin  and  red  corpuscles  is  actually 
increased  in  the  latter  part  of  pregnancy. 

Nervous  System. — The  irritability  of  the  nerve  centers  becomes 
increased.     It  is  likely  that  the  changes  which  take  place  in  the 


36 


PEEGNANCY 


nervous  system  are  entirely  functional.  This  is  the  general  rule, 
to  which,  however,  there  are  some  exceptions.  In  certain  cases 
changes  appear  which  are  serious  in  character  and  can  scarcely  be 
called  functional,  as,  for  instance,  mental  disorders,  chorea,  and 
other  affections  showing  more  or  less  loss  of  regulating  power. 

Respiratory  System. — The  breathing  becomes  more  thoracic  and 
sometimes  embarrassed.  This  is  due  to  the  fact  that  the  uterus, 
as  it  rises  in  the  abdominal  cavity,  presses  against  the  diaphragm 


Fig.  44. — Pendulous  Abdomen  of  a  Multiparous  Woman  with  Normal 
Pelvis,  showing  also  Old  and  New  Stri^  (Williams). 

and  thus  diminishes  the  thoracic  space.  Some  say,  however,  that 
this  space  is  not  much  diminished,  because  as  the  diaphragm 
presses  upward  the  thorax  widens  to  a  slight  extent  at  its  base. 
Some  contend  that  the  vital  capacity  of  the  chest  is  only  slightly, 
if  at  all,  diminished.  I  am  not  sure  whether  this  statement  is 
correct,  but  we  know  from  clinical  experience  that  in  certain  pa- 
tients, especially  in  those  who  have  a  tendency  toward  bronchitis 
or  asthma,  or  both,  there  is  a  certain  amount  of  embarrassment  of 
the  breathing  apparatus,  which  is  caused  by  the  changed  condi- 
tions which  prevail  in  pregnancy. 


CHANGES  IN  THE  MATERNAL  ORGANISM   37 

Osseous  System. — OstcMjphytcs  or  irregular  bony  deposits  are 
frequently  found  between  the  skull  and  dura  mater.  These,  how- 
ever, are  not  peculiar  to  pregnancy  and  are  not  important. 

Urinary  System. — The  urine  is  greater  in  quantity,  possibly 
from  increased  arterial  pressure,  and  is  more  watery.  The  spe- 
cific gravity  is  about  1.014.  Albumin  and  sugar  arc  found  in 
a  certain  proportion  of  cases  without  giving  rise  to  serious 
symptoms. 

Cutaneous  System. — Many  changes  take  place  in  the  skin  dur- 
ing pregnancy.  Pigmentation  occurs  in  certain  parts  of  the  body, 
especially  in  the  breasts,  where  the  areola  becomes  much  darker 
in  color,  and  in  the  abdomen,  where  a  similar  change  takes  place  in 
the  linea  alba.  This  deposit  of  pigment  is  more  marked  in  bru- 
nettes than  in  blondes.  Sometimes  the  skin  of  the  face  shows 
deposits  of  pigment  as  irregular  patches  on  the  forehead  and  the 
neck  (chloasma).  There  is  also  increased  activity  of  the  glands 
of  the  skin,  especially  the  sebaceous  and  sweat-glands.  Some- 
times the  enlargement  of  the  glands  may  cause  lumps,  particularly 
in  the  skin  of  the  axilla;  such  lumps  should  not  be  confounded 
with  supernumerary  breasts  which  sometimes  appear  in  the  same 
position. 

Where  the  skin  is  much  stretched,  as,  for  instance,  on  the  sur- 
face of  the  abdomen,  certain  markings  are  found.  These  are  due 
to  cracks  in  the  skin,  which  are  called  striae,  linese  albicantes,  or 
linese  gravidarum.  They  are  due  to  changes  in  the  corium  caused 
by  stretching,  and  they  lie  at  right  angles  to  the  direction  of  the 
stretching.  The  epidermis  covering  the  cracks  does  not  show  any 
change  in  structure.  The  striae  are  mostly  oblique  in  direction, 
running  downward  and  inward.  The  color  of  these  cracks  is  at 
first  gray  or  pinkish  and  sometimes  a  bluish  purple.  These  lines 
sometimes  grow  whiter  and  more  opaque  after  labor.  If  small 
striae  are  formed  in  subsequent  pregnancy,  the  difference  between 
the  old  and  the  new  is  quite  easily  recognized  (Fig.  44). 

Alimentary  System. — -Although  disturbances  of  the  digestive 
organs  are  apt  to  arise,  it  is  not  likely  that  in  healthy  women 
assimilation  is  often  seriously  affected.  However,  it  happens  in 
a  certain  proportion  of  cases  that  evil  effects  arise  on  account  of 
defective  assimilation,  such  as  osteomalacia,  acute  atrophy  of  the 
liver,  general  toxaemia,  etc.,  which  will  be  considered  in  connec- 
tion with  the  diseases  of  pregnancy. 


38  PEEGNANCY 

Bladder. — The  bladder  is  affected,  to  some  extent,  on  account 
of  the  pressure  of  the  ante  verted  gravid  uterus.  Under  ordinary- 
circumstances  the  position  of  the  uterus  early  in  pregnancy  is 
largely  affected  by  the  condition  of  the  bladder  (full  or  empty). 
As  pregnancy  advances,  however,  the  uterus  ceases  to  be  affected 
by  the  bladder  and  the  conditions  are  reversed ;  that  is,  the  blad- 
der has  to  adapt  itself  to  the  space  available  for  it.  The  bladder 
is  especially  pressed  upon  during  the  first  three  months  of  preg- 
nancy. After  the  uterus  rises  above  the  brim  there  is  for  some 
months  more  room  for  the  bladder  in  the  pelvis.  In  the  last 
couple  of  months,  however,  the  lower  part  of  the  uterus  again 
occupies  a  good  deal  of  space  within  the  pelvis  and  the  bladder  is 
then  much  pressed  upon.  Under  such  circumstances  the  bladder 
frequently  rises  above  the  pubes  in  such  a  way  that  it  lies  between 
the  anterior  abdominal  wall  and  the  uterus.  It  happens  that 
there  is  no  fixed  rule  about  the  position  of  the  bladder  in  the  latter 
part  of  pregnancy,  and  on  this  account  it  is  often  quite  difficult  to 
pass  a  catheter  at  this  time.  Howard  Kelly  says  the  female  blad- 
der expands  physiologically  like  saddle-bags,  most  from  side  to 
side  and  least  in  an  antero-posterior  direction,  and  this  method 
of  distention  becomes  more  marked  in  pregnancy. 

Intestines. — Intestinal  peristalsis  is  generally  impaired  during 
pregnancy.  It  is  especially  important  to  consider  the  condition 
of  the  rectum.  The  pressure  on  the  rectum  is  apt  to  produce  con- 
stipation, sometimes  of  an  obstinate  form.  Another  very  common 
and  serious  condition  is  that  of  piles,  which  is  produced  by 
pressure  on  the  pelvic  veins.  In  a  fairly  large  proportion  of  cases 
haemorrhoids  appear  during  the  first  pregnancy  for  the  first  time, 
and  sometimes  require  careful  and  judicious  treatment. 


DIAGNOSIS  OF  PREGNANCY 

In  a  great  majority  of  cases  pregnant  women  make  their  own 
diagnosis,  and  engage  the  accoucheur  to  attend  them  during  labor. 
The  physician  when  called  on  to  decide  as  to  the  condition  will  get 
little  credit  for  making  a  correct  diagnosis,  while,  on  the  other 
hand,  he  will  be  seriously  blamed  for  a  mistaken  diagnosis.  It  is 
very  important  in  certain  instances  that  no  mistake  be  made, 
especially  where  the  reputation  of  the  patient  is  at  stake. 


DIAGNOSIS    OF    PREGNANCY  39 

It  is  sometimes  exceedingly  difTirult,  if  not  impossible,  to  make 
a  correct  diagnosis.  Under  such  circumstances  it  is  better  to  wait 
for  a  time  and  perhaps  make  repeated  examinations  before  giving 
a  definite  opinion.  Mistakes  in  the  diagnosis  of  pregnancy  happen 
to  be  somewhat  frequent  and  occur  even  in  the  hands  of  very  care- 
ful practitioners. 

A  few  years  ago  a  man  of  large  experience  examined  a  patient 
and  made  a  diagnosis  of  ovarian  tumor.  He  decided  to  operate 
and  made  all  the  necessary  arrangements.  It  was  discovered, 
however,  when  the  woman  was  placed  on  the  table  for  operation, 
that  she  was  pregnant,  nearly  at  full  term.  In  other  cases  which 
might  be  narrated  the  mistake  was  not  detected  until  the  ab- 
domen had  been  opened. 

About  a  year  ago  a  patient  was  sent  to  a  surgeon  of  this  city 
to  be  operated  upon  for  a  supposed  ovarian  tumor.  As  there  was 
considerable  obscurity  about  the  condition  present  I  was  called 
in  consultation.  We  examined  the  patient  very  carefully  under 
chloroform  and  formed  the  opinion  that  there  was  a  pregnancy 
advanced  about  six  months  and  that  the  foetus  was  dead.  The 
patient  denied  the  possibility  of  such  a  condition  and  her  relatives 
were  seriously  offended.  We  were  allowed  shortly  afterward, 
however,  to  empty  the  uterus,  and  found  a  dead  foetus  six  months 
advanced.  In  such  a  case  one  assumes  a  serious  responsibility 
in  giving  a  decided  opinion,  especially  when,  as  in  this  instance, 
the  patient  is  an  unmarried  girl.  It  is  important  in  such  a  case 
to  get  one  or  more  consultants  to  share  the  responsibility. 

A  patient  herself  will  sometimes  make  the  error  of  considering 
that  she  is  pregnant  when  no  such  condition  exists,  and  this  not 
unfrequently  happens  even  with  women  who  have  previously 
borne  children.  Further  references  to  such  mistakes  are  made  in 
connection  with  the  Differential  Diagnosis  of  Pregnancy. 

SIGNS   AND    SYMPTOMS 

The  ordinary  signs  of  pregnancy  have  been  classified  in  various 
ways.  By  some  they  are  divided  into  the  probable,  or  symp- 
tomatic signs  depending  upon  changes  taking  place  in  the  mater- 
nal organism,  and  the  physical  or  direct  signs  produced  by  the 
growth  of  the  uterus  and  the  ovum.  The  simplest  plan  is  to 
considei  the  signs  pretty  much  in  the  order  in  which  they  occur. 


40  PEEGNANCY 

Cessation  of  Menstruation. — The  suppression  of  menstruation, 
or  the  amenorrhoea  of  pregnancy,  is  in  many  respects  the  most  im- 
portant sign,  because  it  is  the  first  which  leads  a  woman  to  suspect 
that  she  is  pregnant.  It  is  not  a  certain  sign.  Irregular  haemor- 
rhages taking  place  during  pregnancy  from  various  causes  are 
frequently  mistaken  for  menstruation.  In  other  instances  it  is 
possible  for  genuine  menstruation  to  occur  during  early  preg- 
nancy, that  is,  during  the  first  three  months,  while  there  is  still  a 
space  between  the  decidua  vera  and  the  decidua  reflexa.  We  hear 
of  cases  in  which  menstruation  has  been  supposed  to  occur  during 
the  whole  of  pregnancy.  There  may  be  haemorrhages  at  any  time 
during  pregnancy,  and  they  may  occur  with  a  certain  amount  of 
regularity,  but  they  are  not  menstrual  discharges  when  they  occur 
during  the  fourth  and  later  months. 

Suppression  of  menstruation,  even  in  the  healthy,  may  occur 
from  various  emotional  and  other  causes.  Such  temporary  cessa- 
tions of  menstruation  without  pregnancy  are  especially  apt  to 
occur  shortly  after  marriage  or  after  illicit  intercourse. 

The  occurrence  of  pregnancy  during  the  amenorrhoea  of  lacta- 
tion is  not  at  all  uncommon.  Many  women  while  nursing  their 
children  become  pregnant  and  have  no  suspicion  of  any  such  con- 
dition until  they  feel  the  motion  of  the  child  within  the  uterus — 
that  is,  quickening. 

Morning  Sickness.  Nausea  and  vomiting  are  common  in  preg- 
nant women,  and  as  the  sickness  occurs  more  frequently  in  the 
morning  it  has  received  the  name  of  morning  sickness.  There 
may  be  simple  nausea  with  no  other  disturbance,  or  there  may  be 
nausea  accompanied  by  retching,  or  there  may  be  nausea  accom- 
panied by  more  or  less  vomiting. 

These  symptoms  commonly  occur  about  the  end  of  the  first 
month,  and  are  generally  relieved  or  mitigated  at  the  end  of  the 
fourth  or  fifth  month.  They  may,  however,  occur  almost  imme- 
diately after  conception  and  continue  through  the  whole  of  preg- 
nancy; on  the  other  hand,  they  may  be  absent  altogether.  It 
happens  in  a  certain  proportion  of  cases  that  the  nausea  and  vomit- 
ing become  so  serious  as  to  require  careful  treatment. 

Changes  in  the  Breast  and  Nipples. — The  mammary  changes 
are  especially  important  in  those  pregnant  for  the  first  time.  They 
sometimes  occur  very  early,  in  which  case  there  may  be  from  the 
very  onset  of  pregnancy  a  sense  of  fulness  and  tenderness  in  the 


DIAGNOSIS    OF    PREGNAXCY 


41 


breasts.  In  the  second  month  a  distinct  enlargement  of  the 
breasts  may  be  apparent,  and  such  enlargement  is  more  mani- 
fest as  pregnancy  advances.  As  the  enlargement  takes  place 
chiefly  in  the  glandular  tissue  the  breast  has  a  knotty  feeling ;  in 
the  latter  months  the  large  blue  veins  may  be  distinctly  visible 
under  the  skin.  Changes  in  the  nipples  and  the  areolse  are  still 
more  pronounced.  The  nipples  generally  become  more  prom- 
inent and  are  often  covered  with  minute  branny  scales  due  to  the 
drying  of  the  secre- 
tion which  oozes 
from  them.  A  sec- 
ondary areola  may 
be  visible  during  and 
after  the  fifth  month 
and  its  presence  af- 
fords a  strong  pre- 
sumption of  preg- 
nancy. In  the  latter  part  of 
pregnancy  the  breasts  droop 
to  a  certain"  extent,  causing 
the  nipples  to  become  directed 
downward,  and  thus  better 
adapted  for  the  infant  to  seize. 

Secretion  in  the  breasts  begins  early, 
and  a  clear  liquid  may  be  squeezed 
from  the  nipple  as  early  as  the  third 
month.  The  fluid,  however,  which  is 
formed  in  the  gland  early  in  pregnancy 
is  not  milk,  but  a  mucoid  fluid  which 
is  quite  clear  and  transparent.  After 
a  time  microscopical  examination  re- 
veals colostrum  corpuscles  which  are  similar  to  those  found  in  the 
breast  secretion  immediately  after  delivery.  Changes  in  the  breast 
similar  to  those  described  may  occur  with  various  uterine  and 
ovarian  disorders  and  in  those  cases  of  imaginary  pregnancy  called 
pseudocyesis. 

Changes  in  Size,  Shape,  and  Consistency  of  the  Uterus. — The 
uterus  commences  to  enlarge  shortly  after  fecundation  of  the  egg. 
The  increase  in  the  size  of  the  body  is  chiefly  in  the  antero-posterior 
diameter  during  the  first  few  weeks,  changing  the  pear  shape  of 


Fig.  45. — Bimanual  Exam- 
ination SHOWING  NO 
Enlargement  of  the 
Uterus. 


42 


PEEGNA^TCY 


the  uterus  into  that  of  an  "old-fashioned  fat-belHed  jug"  (Par- 
vin).  This  "behying"  of  the  uterine  body  can  generally  be  de- 
tected in  front  of  and  above  the  cervix  by  one  or  two  fingers  in  the 

vagina,  while  the  uterus  is 
pushed  downward  by  the  other 
hand.  The  body  of  the  uterus 
also  becomes  soft,  doughy, 
and  elastic.  This  change  in 
consistency  can  generally  be 
detected  on  bimanual  exami- 
nation. 

Hagar's  sign  appears  early 
in  pregnancy,  about  the  sixth 
week,  and  depends  on  the 
softening  of  the  lower  uterine 
segment,  which  gives  the  im- 
pression to  one  making  a  com- 
bined examination  that  the 
body  and  the  cervix  of  the 
uterus  are  disconnected.  One 
or  two  fingers  are  passed  into 
the  vagina,  or  the  thumb  is 
passed  into  the  vagina  and  a 
finger  into  the  rectum,  while 
the  fundus  is  pressed  down  by  the  other  hand  from  above.  A 
great  deal  of  importance  is  attached  to  this  sign  by  many,  but  it 
does  not  always  point  to  pregnancy.  This  softened  condition  of 
the  lower  uterine  segment  may  sometimes  be  found  in  the  non- 
pregnant uterus,  being  caused  by  congestion  or  inflammation  pro- 
duced by  tumors,  etc. 

Softening  of  the  Cervix  and  Enlargement  of  the  Os. — The  cervix 
begins  to  soften  in  its  texture  during  the  first  month  of  pregnancy, 
owing  to  the  congestion  and  the  effusion  of  serum  into  its  sub- 
stance. In  the  latter  part  of  pregnancy  the  softening  is  sometimes 
so  extreme  that  a  beginner  may  find  it  difficult  to  distinguish  the 
cervix  from  the  vagina.  The  softening  is  superficial  in  the  first 
month,  is  more  marked  by  the  fourth  month,  and  reaches  its  ex- 
treme extent  in  the  seventh  or  eighth  month. 

The  cervical  glands  secrete  a  larger  amount  of  mucus  during 
pregnancy  than  under  ordinary  circumstances.     It  is  this  tena- 


FiG.  46. — Bimanual  Examination  show 
iNG  "  Bellying  "  of  Uterus. 


DIAGNOSIS    OF    PPtEGNANCY 


43 


cious  mucus  which  forms  the  cervical  jjlug  or  operculum.  The 
external  os  becomes  niore  patulous  than  it  was  before  impregna- 
tion. In  most  cases  the  finger  may  be  easily  introduced  within 
the  OS  during  tlie  last  three  months  of  pregnancy  in  multipara?, 
but  not  iu  pi'imipar;e. 

Changes  in  the  Vaginja. — The  changes  in  the  color  of  the  vaginal 
mucous  membrane  from  normal  to  a  dark  purplish  appear  early  in 
pregnancy  and  arc  due  to  venous  congestion.  The  vaginal  walls 
become  thickened  and  are  thrown  into  folds  which  sometimes  pro- 
trude slightly  from  the  vaginal  orifice.     The  laxity  of  the  mucous 


Fig.   47. — Method  of  detecting  Hegar's  Sign  (Williams). 


membrane  is  well  marked  after  the  sixth  month  and  there  is  also 
a  secretion  of  mucus. 

Hypertrophy  of  the  Ureters. — Palpate  back  of  the  S3'mphysis 
with  finger  in  the  vagina  and  then  starting  above  at  one  side  of  the 


44 


PREGNANCY 


joint  draw  the  finger  downward  and  slightly  outward  along  the 
back  of  the  pubes.  Jellett  says  that  the  ureter,  which  here  lies 
back  of  the  pubes  between  the  anterior  vaginal  and  the  posterior 
bladder  wall,  is  displaced  forward  against  the  pubes  and  is  felt  to 

slip  from  under  the 
finger.  It  is  not  easy 
to  distinguish  whether 
it  is  enlarged  or  not, 
but  Jellett  adds  that 
if  it  is  felt  at  all  by 
the  student  it  is  prob- 
ably hypertrophied, 
because  it  is  difficult 
to  feel  a  non-hyper- 
trophied  ureter. 

Ballottement. — 
This  word  is  derived 
from  halloter,  to  toss 
up  like  a  ball.  It 
means  the  sensation 
imparted  to  the  fingers 
when  they  are  placed 
beneath  the  foetus  as 
it  lies  in  the  body  of 
the  uterus  and  is 
tossed  up  in  the  liquor 
amnii.  The  Avoman 
is  placed  on  her  back, 
or  in  a  position  mid- 
way between  sitting 
and  lying.  As  Gala- 
bin  describes  it,  the 
finger  in  the  vagina 
with  its  tip  resting  just 
in  front  of  the  cervix 
should  give  a  sudden  but  gentle  push  or  jerk  upward.  The 
foetus  is  then  felt  to  recede  from  the  finger  and  after  a  moment's 
interval  to  return  with  a  gentle  tap.  The  physician  may  not  be 
able  to  feel  the  return  tap,  but  if  he  feels  the  hard  body  (the 
foetus)    recede   and   finds    after  a   moment   or   two   that   it   has 


Fig.  48. — Height  of  Fundus  Uteri. 

Five  months,  between  symphysis  pubis  and  umbilicus ; 
six  months,  at  umbiUcus;  seven  months,  half-way 
between  umbilicus  and  ensif  orm  cartilage ;  eight  and 
nine  months,  near  ensiform  cartilage,  sinking  in 
latter  part  of  ninth  month. 


DIAOXOSTS    OF    PT^EGXAXCY  45 

returned  to  its  former  position  he  may  consider  that  he  has 
obtained  the  characteristic  evidence  furnished  by  this  sign. 

Foetal  Movements. — The  movements  of  the  foetus  are  usually 
felt  by  the  mother  when  pregnancy  is  about  four  and  one-half 
months  advanced,  but  the  time  of  such  occurrence  is  very  variable. 
This  sensation  of  movement  which  the  mother  notices  is  called 
quickening,  and  is  first  hoticed  when  the  uterus  rises  sufficiently 
into  the  abdomen  to  come  in  contact  with  the  abdominal  walls. 
The  foetal  movements  become  more  evident  and  much  stronger 
as  pregnancy  advances  and  may  often  be  seen  as  well  as  felt  during 
the  later  months. 

Quickening  is  of  much  importance  in  certain  cases  where  it 
furnishes  to  the  woman  the  first  sign  of  pregnancy.  Recognition 
of  foetal  movements  by  abdominal  palpation  proves  to  us  not  only 
that  pregnancy  exists,  but  also  that  the  foetus  is  living.  This  is 
often  of  great  importance  when  the  foetal  heart  sounds  can  not  be 
heard.  The  subjective  sign  of  quickening — that  is,  the  feeling  of 
foetal  movements  by  the  mother,  should  not  be  considered  in  any 
case  a  positive  sign  of  pregnancy.  Even  women  who  have  before 
borne  children  may  be  deceived  and  may  mistake  intestinal  move- 
ments for  those  of  the  foetus,  as,  for  instance,  in  cases  of  pseudocye- 
sis.  It  is  sometimes  difficult  even  for  the  physician  to  be  certain 
of  foetal  movements  which  may  be  simulated  by  movements  of 
the  intestines  or  of  the  abdominal  muscles. 

Foetal  Heart  Sounds. — By  auscultation  over  the  abdomen  of  a 
pregnant  woman  several  different  sounds  can  be  heard.  The  fol- 
lowing are  mentioned  by  Smyly:  foetal  heart  sounds,  uterine 
souffie,  funic  or  umbilical  souffle,  maternal  heart  sounds,  respira- 
tory murmur  of  the  mother,  movements  of  the  child,  friction  be- 
tween the  uterus  and  the  abdominal  wall,  crepitating  noises  due 
to  air  in  the  uterus  or  abdominal  walls,  the  muscular  susurrus — 
that  is,  the  note  given  out  by  contracting  muscle-fiber. 

The  foetal  heart  sounds  are  said  to  resemble  the  ticking  of  a 
watch  beneath  a  pillow,  but  it  is  better  for  one  to  learn  them  by 
listening  to  the  heart  of  a  young  infant  soon  after  birth.  The  sound 
is  really  double,  but  in  a  large  proportion  of  cases  only  the  first  can 
be  heard.  The  rate  varies  between  120  and  160  in  the  minute. 
It  is  much  affected  by  accidental  circumstances.  Active  foetal 
movements  sometimes  increase  the  rapidity  to  the  extent  of  twenty 
beats  in  the  minute.     The  condition  of  the  mother  often  affects 


46  PEEGNANCY 

the  rate.  When  the  rate  of  the  mother's  pulse  is  increased  by- 
fever  or  other  causes  the  foetal  pulse  may  also  be  increased,  al- 
though not  in  a  proportionate  degree.  During  a  labor  pain  the 
foetal  heart  becomes  slower  and  resumes  its  ordinary  rate  during 
the  interval  between  the  pains.  In  a  tedious  labor,  if  the  vitality 
of  the  foetus  is  lowered  by  long  continued  pressure,  the  foetal  heart 
rate  becomes  slower.  In  such  a  case  the  foetal  heart  often  be- 
comes slower  while  the  mother's  pulse  is  becoming  more  rapid. 
Diminished  rapidity  of  the  foetal  pulse  is  often  an  indication  of 
danger  to  the  child's  life. 

The  foetal  heart  sounds  are  acknowledged  by  all  to  furnish  the 
most  valuable  sign  of  pregnancy.  A  recognition  of  such  sounds 
proves  beyond  a  doubt  that  a  living  foetus  exists.  After  we  have 
discovered  the  evidence  of  a  living  foetus  the  only  doubt  that  can 
arise  is  due  to  the  possibility  of  an  extra-uterine  instead  of  a  uter- 
ine pregnancy. 

The  foetal  heart  is  most  frequently  heard  at  a  point  half-way 
between  the  umbilicus  and  the  center  of  Poupart's  ligament  on  the 
left  side.  This  is  because  the  sounds  are  best  transmitted,  as  a 
rule,  through  the  back  of  the  foetus  and  when  the  foetus  is  in  the 
first  or  most  common  position,  with  its  back  directed  toward  the 
left  front  of  the  mother's  abdomen.  In  the  second  position,  when 
the  back  of  the  child  is  directed  toward  the  right  front  of  the 
mother's  abdomen,  the  sound  is  of  course  best  heard  on  the  right 
side.  In  face  presentation  the  heart  sounds  are  heard  better 
through  the  thorax  than  through  the  back.  In  other  cases  when 
the  back  of  the  foetus  is  lying  posteriorly  the  foetal  heart  is  heard 
with  difficulty  or  not  at  all. 

The  only  mistake  which  is  likely  to  arise  is  that  due  to  hearing 
the  mother's  pulse  instead  of  the  foetal  heart.  Generally  speak- 
ing, one  can  easily  distinguish  between  them  by  comparing  the 
rate  of  the  pulse  of  the  mother  with  that  of  the  foetus.  Some- 
times when  the  woman's  pulse  is  rapid  there  may  be  some  diffi- 
culty. However,  even  in  that  case,  if  one  listens  with  the  stetho- 
scope and  feels  the  radial  artery  at  the  same  time,  it  will  be  found 
that  the  two  pulses  will  not  continue  simultaneous  for  any  length 
of  time,  one  is  sure  to  be  slower  than  the  other  in  time. 

It  is  thought  by  some  that  the  pulse  rate  may  be  of  some  value 
m  distinguishing  the  sex.  If,  for  instance,  the  foetal  pulse  is  140 
or  more  it  is  likely  that  there  is  a  female  child ;  if  it  falls  below 


DIAGNOSIS    OF    PREGNANCY  47 

140  it  is  likely  to  be  a  male  child.  However,  when  we  remember 
that  the  rapidity  of  the  heart  varies  in  the  same  children  at  differ- 
ent times  and  that  it  depends  largely  on  the  size  of  the  child,  we 
can  easily  see  that  the  sign  is  not  of  much  importance. 

Uterine  Souffle. — The  uterine  souffle  is  a  blowing  sound  syn- 
chronous with  the  mother's  pulse,  generally  heard  on  one  or  both 
sides  of  the  body  of  the  uterus,  but  most  frequently  in  the  left 
flank.  The  sound  has  been  compared  to  the  puffing  of  an  engine 
of  a  goods  train  going  slowly  and  heard  from  a  distance.  It  was 
at  one  time  called  the  placental  souffle,  because  it  was  thought  that 
it  had  its  origin  in  the  placenta.  That  this  is  not  the  case  is  proved 
by  the  fact  that  it  may  be  heard  for  some  time  after  dehvery  and 
also  that  a  similar  sound  may  be  heard  in  some  cases  of  uterine 
tumors.  The  sound  is  produced  in  the  large  arteries  which  come 
from  the  broad  ligaments  and  enter  the  uterine  walls. 

The  sound  is  first  heard  about  the  end  of  the  fourth  month  and 
continues  until  the  time  of  labor  and  for  a  certain  time  into  the 
puerperium.  In  the  earlier  months  one  may  hear  it  by  placing 
the  stethoscope  close  above  the  pubes  on  either  side.  As  a  sign 
of  pregnancy  it  is  sometimes  especially  valuable,  since  it  may  be 
heard  before  the  foetal  heart  sounds,  and,  although  it  may  occasion- 
ally be  heard  when  uterine  tumors  are  present,  we  know  that  such 
tumors  are  rarely  associated  with  amenorrhea.  We  also  know 
that  tumors  no  larger  than  a  foetus  five  months  old  seldom  pro- 
duce a  souflfle. 

The  souffle  in  the  pregnant  uterus  varies  more  in  quahty, 
pitch,  and  tone  than  that  produced  from  the  presence  of  tumors. 
In  fact,  the  souffle  in  pregnancy  is  said  to  be  more  or  less  musical, 
and  is  sometimes  composed  of  several  notes  which  form  a  sort  of 
chord  in  the  rhythmic  contractions  which  constantly  take  place 
during  pregnancy. 

Intermittent  Uterine  Contractions. — Gentle,  painless  contrac- 
tions of  the  uterine  wafls  take  place  at  regular  intervals  during  the 
whole  of  pregnancy.  Each  contraction  produces  a  tense  condition 
lasting  for  a  minute  or  two,  or  about  as  long  as  a  regular  labor  pain. 
Each  contraction  is  followed  by  a  relaxation  lasting  about  ten  to 
fifteen  minutes.  These  contractions  and  relaxations  may  be  de- 
tected as  soon  as  the  uterus  rises  from  the  pelvic  cavity  and  comes 
in  contact  with  the  abdominal  wall,  and  become  more  distinct  as 
pregnancy  advances.  During  the  intervals  of  relaxation  the  foetus 
5 


48  PEEGNANCY 

can  generally  be  felt  through  the  uterine  walls,  which  are  then 
quite  flaccid.  During  the  contraction  the  foetus  can  not  be  so  dis- 
tinctly felt.  The  uterus  becomes  more  pyriform  in  shape  and 
more  prominent  in  front.  Although  uterine  contractions  may  be 
caused  by  the  presence  of  certain  tumors  they  are  not  so  distinct 
in  the  latter  case  as  when  they  are  caused  by  pregnancy. 

Funic  or  Umbilical  Souffle. — The  umbihcal  souffle  is  a  mur- 
mur which  is  produced  in  the  vessels  of  the  cord,  probably  the 
umbilical  vein,  and  is  synchronous  with  the  foetal  pulse.  The  mur- 
mur is  generally  produced  in  the  cord  at  some  point  where  it  is 
subjected  to  pressure  or  twisted.  It  may  be  heard  toward  the 
end  of  pregnancy  in  about  10  per  cent,  of  cases.  This  murmur  is 
of  very  little  practical  importance. 

Other  Sounds, — Some  other  sounds  of  no  great  importance  may 
sometimes  be  heard.  Among  these  are  the  sounds  produced  by 
the  movements  of  the  child  or  by  friction  between  the  uterine 
and  abdominal  walls.  Certain  crepitating  sounds,  due  to  the 
presence  of  air  in  the  uterus,  may  also  occasionally  be  heard. 


DIFFERENTIAL  DIAGNOSIS  OF  PREGNANCY 

The  following  conditions  may  be  mistaken  for  pregnancy: 
(1)  Those  which  increase  the  size  of  the  uterus ;  physometra,  hydro- 
metra,  haematometra,  uterine  fibroids.  (2)  Those  which  increase 
the  size  of  the  abdomen  from  growths,  etc.,  outside  the  uterus ; 
ovarian  tumors,  enlarged  organs  and  malignant  tumors  within  the 
abdomen,  ascites,  accumulation  of  fat  in  abdominal  walls  or  omen- 
tum, spurious  or  false  pregnancy. 

Physometra. — This  is  a  collection  of  gas  in  the  uterus  frequently 
due  to  the  decomposition  of  fragments  of  the  ovum.  If  large 
enough  for  percussion  a  tympanitic  sound  will  show  the  nature  of 
the  enlargement,  while  at  the  same  time  palpation  and  ausculta- 
tion will  not  furnish  the  ordinary  sign  of  pregnancy.  The  most 
common  cause  is  atresia  or  some  form  of  stenosis. 

Hydrometra. — This  is  a  collection  of  watery  fluid  which  is  re- 
tained on  account  of  occlusion  of  the  os.  As  in  the  case  of  physo- 
metra the  increase  in  the  size  of  the  uterus  is  slow.  The  uterus  is 
seldom  found  to  be  larger  than  an  orange.  It  generally  appears 
in  women  who  have  passed  the  menopause. 


DIFFERENTIAL    DIAGNOSIS    OF    PREGNANCY      49 

Haematometra. — This  is  an  accumulation  of  menstrual  blood  in 
the  uterus  which  is  due  to  cither  C()n<^enital  or  accjuired  atresia  of 
some  portion  of  the  genital  canal.  Such  atresia  may  be  readily 
detected  by  physical  examination.  Errors  of  diagnosis  due  to 
such  accunuilatious  are  unfortunately  not  very  rare.  In  studying 
the  history  of  the  enlargement  of  the  uterus  in  such  cases  we  gen- 
erally find  that  it  has  lasted  for  a  long  period  and  that  it  has 
increased  periodically  rather  than  continuously.  The  rapid  in- 
crease which  occurs  periodically  is  generally  attended  by  severe 
pain  and  usually  occurs  once  a  month.  The  uterus  is  found  on 
palpation  to  be  tense  and  resisting,  not  elastic  and  yielding  as  it 
generally  is  in  pregnancy.  On  palpation  also  no  foetal  parts  are 
felt  and  auscultation  furnishes  none  of  the  ordinary  sounds  caused 
by  pregnancy. 

Uterine  Fibroids. — These  tumors,  more  properly  termed  my- 
omata,  are  not  infrequently  mistaken  for  pregnancy.  When  the 
uterus  is  enlarged  on  account  of  the  presence  of  fibroids,  it  is  gen- 
erally irregular  in  shape  and  hard  and  resisting  instead  of  elastic 
and  yielding.  There  is  usually  metrorrhagia  (irregular  and  profuse 
hcemorrhage)  instead  of  amenorrhcea. 

Ovarian  Tumors. — Menstruation  is  generally  present  with  ova- 
rian tumor,  but  amenorrhoea  is  occasionally  produced.  Under 
such  circumstances  the  cessation  of  menstruation  comes  on  grad- 
ually. In  ovarian  tumors  there  are  no  heart  sounds  and  no  foetal 
movements.  The  enlargement  is  generally  observed  on  one  side 
of  the  abdomen  rather  than  in  the  median  line  and  its  develop- 
ment is  slower  than  that  of  pregnancy.  When  a  patient  has 
an  ovarian  tumor  there  is  generally  marked  deterioration  of 
health  with  emaciation,  the  latter  being  especially  noticeable  in 
the  face. 

Enlarged  Organs  and  Malignant  Omental  and  Mesenteric 
Growths. — Certain  organs  within  the  abdominal  cavity  which 
become  enlarged  from  any  cause  may  be  mistaken  for  a  pregnant 
uterus.  Such  enlarged  organs,  however,  develop  from  above  down- 
ward, and  can  generally  be  mapped  out  by  percussion.  We  get 
the  dulness  above  the  Une  of  the  lower  edge  and  a  resonant  strip 
below.  Misplaced  organs,  like  the  kidney  and  spleen,  may  gener- 
ally be  pushed  upward.  Malignant  tumors  of  the  omentum  and 
mesenteric  glands  are  lumpy  and  fixed,  and  nearly  always  grow 
more  slowly  than  a  pregnant  uterus. 


50  PEEGNANCY 

Ascites. — Enlargement  of  the  abdomen,  caused  by  a  collection 
of  fluid  within  the  abdominal  cavity,  has  sometimes  been  mistaken 
for  a  pregnant  uterus.  A  differential  diagnosis,  however,  of  the 
two  conditions  is  a  comparatively  easy  matter.  In  addition  to 
the  ordinary  signs  of  ascites  the  uterus  is  unchanged  in  form,  size, 
and  position,  while  menstruation  is  generally  uninterrupted  and 
the  ordinary  reflex  disturbances  of  pregnancy  are  absent.  There 
is  also,  generally,  an  obvious  cause  for  the  ascites,  usually  disease 
of  the  liver,  kidneys,  or  heart. 

Accumulation  of  Fat  in  the  Abdominal  Wall  or  Omentum. — 
There  is  very  frequently  a  marked  and  rapid  increase  in  the  size  of 
the  abdomen,  especially  in  women  forty  to  fifty  years  of  age,  which 
is  due  to  the  accumulation  of  fat  in  the  abdominal  wall  or  in  the 
omentum.  In  such  cases  the  abdominal  wall  becomes  not  only 
prominent  but  pendant,  and  the  woman  has,  as  Dr.  Bailey  ex- 
pressed it,  "a  double  chin  in  the  belly."  There  is  an  entire 
absence  of  the  ordinary  signs  of  pregnancy  as  discovered  by  aus- 
cultation and  abdominal  palpation.  It  is  generally  easy  when  the 
patient  is  lying  down  for  one  who  places  a  hand  on  each  side 
of  the  abdomen  to  include  between  the  hands  the  mass  of  fat 
and  partially  lift  it  up,  thus  showing  its  true  character. 

Pseudocyesis  or  False  Pregnancy. — This  singular  condition  is 
said  by  some  to  occur  in  women  who  have  married  late  in  life, 
especially  when  they  are  very  anxious  to  have  children.  We, 
however,  find  it  in  women  who  have  borne  children,  especially  in 
those  who  have  had  a  number  of  children  in  early  married  life 
with  a  considerable  interval  before  the  menopause.  In  some  of 
these  cases  abdominal  enlargement  may  exist,  menstruation  may 
cease,  the  breasts  may  become  large  and  painful  and  contain  milk, 
the  ordinary  signs  of  stomach  derangement  may  be  present,  and 
generally  the  patient  is  positive  that  she  can  feel  the  movements 
of  the  fcEtus.  It  may  go  on  so  far  as  to  be  followed  by  what  is 
called  spurious  labor.  In  such  cases  the  patient  feels  certain  that 
she  has  ordinary  labor  pains.  We  know  that  these  supposed 
symptoms  are  due  to  some  perversity  of  the  nervous  system,  and 
yet  the  aetiology  is  to  a  certain  extent  obscure.  In  most  cases  the 
women  are  perfectly  honest  in  their  belief  and  have  no  desire  to 
deceive  others. 

In  such  cases  the  physician  who  makes  no  special  inquiries  or 
examination,  but  trusts  entirely  to  the  statements  of  his  patient, 


DURATION    OF    PREGNANCY  51 

may  easily  be  deceived.  In  attempting  to  make  a  diagnosis  he 
should  attach  little  or  no  weight  to  the  subjective  signs  of  preg- 
nancy. A  careful  examination  will  generally  enable  him  to  find 
the  true  condition  of  affairs.  If,  after  making  an  examination  in 
the  ordinary  way,  there  is  still  some  doubt  as  to  the  condition,  it 
is  well  to  have  an  ana3sthetic  administered.  Anaesthesia  makes  the 
diagnosis  a  very  simple  matter.  I  have,  however,  seen  two  pa- 
tients in  whom  for  certain  reasons  there  was  some  difficulty  in 
arriving  at  a  correct  diagnosis.  In  one  instance  the  patient  was 
so  positive  that  pregnancy  existed  that  she  would  scarcely  submit 
to  anything  like  a  proper  examination.  It  is  sometimes  an  exceed- 
ingly difficult  matter,  as  well  as  a  very  thankless  task,  to  convince 
a  woman  under  such  circumstances  that  she  is  mistaken.  I  know 
another  case  where  the  doctor  made  a  very  casual  examination, 
asked  a  few  questions,  and  predicted  that  labor  would  come  on  a 
certain  date.  A  nurse  was  brought  from  a  neighboring  town  and 
kept  for  a  month  in  the  house  waiting  for  the  labor  which  never 
came.  In  this  case  both  the  doctor  and  patient  were  greatly 
humiliated. 

Pregnancy  combined  with  Fibroid  or  other  Tumors. — Myomata, 
ovarian  tumors,  malignant  tumors,  ascites,  and  enlarged  abdom- 
inal organs  may  coexist  with  pregnancy.  This  is  especially  the 
case  in  reference  to  uterine  fibroids  and  ovarian  tumors.  When 
one  or  more  of  these  conditions  coexist  with  pregnancy  ther6  is 
sometimes  great  difficulty  in  making  an  accurate  diagnosis  and  in 
deciding  as  to  the  best  form  of  treatment. 


DURATION  OF  PREGNANCY 

There  are  certain  reasons  which  prevent  us  from  determining 
the  exact  date  of  conception.  The  only  date  that  we  can  be  cer- 
tain about  which  we  have  to  reckon  from  is  that  of  the  last  men- 
struation. Those  who  have  studied  carefully  the  statistics  of  the 
subject  tell  us  that  the  average  duration  of  pregnancy  is  from  271 
to  276  days.  The  question  of  the  duration  of  pregnancy  derives  its 
chief  interest  in  certain  cases  from  medico-legal  considerations. 
Sometimes  the  courts  have  to  decide  as  to  the  legitimacy  of  a 
child  that  has  been  born  at  an  interval  longer  than  usual  after  the 
last  possible  date  of  coitus  with  the  husband.     In  England  and 


52  PEEGXAN^CY 

America  there  is  no  absolute  limit  laid  down,  and  each  case  has  to 
be  judged  on  its  own  merits.  In  America  the  legitimacy  has  been 
allowed  after  intervals  of  313  to  317  days.  The  laws  of  Scotland, 
Austria,  and  France  allow  a  possible  limit  of  300  days,  while  those 
of  Prussia  allow  one  of  302  days. 

As  intimated  before,  we  can  arrive  at  a  more  definite  conclu- 
sion as  to  when  pregnancy  will  terminate,  or  when  labor  will  com- 
mence, by  considering  the  date  of  the  commencement  of  the  last 
menstrual  period.  In  the  great  majority  of  cases  the  ovum  which 
escaped  at  the  last  menstruation  is  the  one  impregnated,  and  labor 
is  most  apt  to  occur  at  the  time  when  the  patient  ought  to  men- 
struate. If,  then,  we  add  to  the  date  of  the  first  day  of  the  last 
occurring  menstruation  ten  lunar  months,  or  280  days,  we  should 
get  the  probable  date  of  the  commencement  of  labor.  A  common 
method  is  to  add  nine  calendar  months  to  (or  what  amounts  to  the 
same,  subtract  three  calendar  months  from)  the  date  of  the  first 
day  of  the  last  menstruation  and  add  seven  days  to  the  date  thus 
found.  For  instance,  if  the  last  menstruation  commenced  on  May 
10th,  the  day  nine  calendar  months  from  that  would  be  February 
10th.  The  addition  of  seven  will  give  the  probable  date  of  deliv- 
ery, February  17th.  Or  we  may  take  the  date  of  the  commence- 
ment of  the  last  menstruation  and  count  from  that  280  days. 
Such  calculation  should  indicate  the  date  of  expected  labor.  Most 
tables  are  founded  on  this  method  of  calculation. 

In  certain  cases  we  can  not  rely  on  the  date  of  menstruation  at 
all,  for  instance,  when  conception  takes  place  during  a  period  of 
amenorrhoea  or  when  irregular  haemorrhages  take  place  during  the 
early  part  of  pregnancy.  In  some  cases  we  have  to  rely  to  some 
extent  on  the  time  of  quickening.  As  quickening  generally  takes 
place  about  the  middle  of  pregnancy,  we  may  form  some  idea  of 
the  time  of  expected  labor  by  adding  four  and  one-half  months  to 
the  date  when  quickening  was  first  felt. 

There  are  two  other  methods  by  which  we  may  get  some  idea 
and  perhaps  a  pretty  definite  one  as  to  how  far  pregnancy  has 
advanced. 

1.  By  Determining  the  Size  of  the  Uterus.  We  can  get  a  fair 
idea  of  the  size  of  the  uterus  by  a  bimanual  examination  during 
the  early  part  of  pregnancy,  before  the  fundus  has  reached  the 
level  of  the  brim  of  the  pelvis.  Such  an  examination  will  enable 
us  to  decide  approximately  how  far  pregnancy  has  advanced. 


DIAGNOSIS    OF    PliEVIOUS    riiEGNANCY  53 

After  the  fundus  passes  above  the  level  of  the  brim  we  can  ascer- 
tain the  height  of  the  uterus  by  external  examination.  (Fig.  48.) 
2.  Length  of  Faial  Ovoid.  Tliis  is  said  by  some  to  give  the 
most  reliable  data.  In  trying  to  discover  the  length  of  the  ffjctal 
ovoid  one  should  first  make  out  that  the  foetus  is  in  its  normal 
attitude  of  flexion.  One  arm  of  a  i)air  of  calipers  is  then  intro- 
duced into  the  vagina,  antl  the  end  is  placed  on  the  lowest  point 
of  the  child's  head  felt  through  the  anterior  vaginal  wall ;  the  other 
is  then  introduced  over  the  highest  point  of  the  breech  on  the 
abdominal  wall.  According  to  Dakin  the  following  numbers  will 
then  be  a  guide  as  to  measurements  thus  obtained : 

Weeks 26      28      30      32      34      36      38      40 

Length  in  inches.    7.2     7.6     7.9     8.3     8.8     9.2     9.5     9.7 


DIAGNOSIS  OF  PREVIOUS  PREGNANCY 

In  some  cases  it  may  be  important  from  a  medico-legal  point 
of  view  to  know  whether  a  woman  is  pregnant  for  the  first  time, 
or  whether  there  has  been  a  previous  pregnancy  which  has  gone 
on  to  full  term.  In  the  woman  pregnant  for  the  first  time  the 
abdominal  wall  is  generally  smooth,  tense,  and  resisting,  so  that 
it  can  not  be  easily  depressed ;  while  in  succeeding  pregnancies  the 
skin  of  the  abdominal  wall  is  not  smooth  but  relaxed.  In  first 
pregnancies  the  uterus  is  more  apt  to  be  confined  to  the  vicinity 
of  the  median  line  and  does  not  incline  to  the  front  so  much  as  it 
does  in  succeeding  pregnancies.  In  first  pregnancies  the  mammary 
glands  are  generally  round  and  firm  instead  of  being  relaxed, 
flabby,  and  pendant.  The  vulvar  orifice  is  small  and  closed  and 
the  posterior  commissure  is  complete.  The  vagina  is  comparatively 
small  and  the  neck  of  the  uterus  is  conical,  its  closed  orifice  show- 
ing a  uniform  rim  or  border.  As  mentioned,  however,  by  Parvin, 
it  has  been  observed  by  Kleinwatcher  that  all  these  signs  have 
only  a  relative  value.  The  striae  upon  the  abdomen  and  breasts 
and  the  tears  of  the  cervix  may  be  wanting,  the  perinseum  may 
be  entire,  and  yet  the  patient  may  have  been  pregnant.  The 
signs  of  a  previous  pregnancy  are  chiefly  the  results  of  mechanical 
force  produced  by  carrying  and  giving  birth  to  a  large  fcBtus. 
They  may,  therefore,  be  in  part  or  entirely  absent,  provided  the 
flrst  labor  was  premature  and  the  foetus  too  small  to  produce  any 


54  PEEGNANCY 

injury  from  distention  or  tears.  It  should  also  be  remembered 
that  abdominal  striae  may  be  due  to  great  abdominal  distention 
from  ascites  or  the  presence  of  an  ovarian  tumor.  If  several  years 
elapse  between  two  labors  the  soft  parts  may  be  so  nearly  restored 
to  their  original  condition  that  it  will  be  impossible  to  decide 
whether  the  person  is  a  multipara  or  a  primipara. 


PELVIMETRY 

This  means  the  process  of  measuring  the  pelvis.  We  have 
passed  through  various  phases  of  thought  in  connection  with 
deformities  of  the  pelvis  and  a  proper  estimate  of  them  by  correct 
pelvimetry.  Many  were  inclined  years  ago  to  think  that  pelvic 
deformity,  while  comparatively  common  in  the  older  countries, 
was  very  rare  in  America.  It  was,  of  course,  always  understood 
that  we  occasionally  met  with  a  generally  contracted  or  a  flat 
pelvis  through  which  it  was  impossible  to  extract  an  ordinary 
child,  but  it  was  somewhat  easy  to  recognize  such  a  pelvis  in 
the  dwarf,  the  humpback,  etc.  We  tried  to  do  our  duty  by 
making  use  of  pelvimetry  to  a  certain  extent.  Unfortunately, 
the  subject  was  greatly  obscured  by  the  multiplicity  of  methods 
described. 

We  found  that  "complete"  pelvimetry  was  a  very  tedious 
procedure  involving  great  exposure  of  the  patient  and  much  ma- 
nipulation, all  of  which  were  very  distasteful  to  her.  It  was  not 
the  custom  in  private  practice  in  England  to  carry  out  such  meas- 
urements. It  was  not  often  attempted  even  in  hospital  practice. 
In  recent  years  pelvimetry  has  become  common  in  most  of  the 
British  lying-in  hospitals,  but  not  in  private  practice.  On  the 
Continent,  and  especially  in  France  and  Germany,  routine  pel- 
vimetry has  been  carried  out  in  hospitals  and  to  a  certain  extent 
in  private  practice  for  some  time.  A  few  years  ago  such  men  as 
Parvin  and  Lusk  in  the  United  States  described  the  French  and 
German  methods  of  pelvimetry,  but  expressed  the  opinion  that 
pelvic  deformity  was  very  rare  among  native-born  women.  So 
far  as  I  know,  Whitridge  WiUiams  was  the  first  in  that  country  to 
properly  carry  out  routine  pelvimetry.  He  was  thus  enabled  to 
demonstrate  the  fact  that  the  proportion  of  women  with  con- 
tracted pelves  in  the  United  States  was  much  greater  than  had 


PELVIMETEY  55 

previously  been  supposed  by  Parvin,  Lusk,  and  others.  Williams 
and  Robbins  found  in  1,000  consecutive  cases  of  labor  130  con- 
tracted pelves,  that  is  to  say,  about  13  per  cent. 

Methods. — Since  we  have  carried  out  routine  pelvimetry  in  the 
public  wards  of  the  Burnside  Lying-in  Hospital,  we  have  discov- 
ered a  fairly  large  proportion  of  pelvic  deformities.  We  have 
endeavored  to  simplify  oiir  methods  as  much  as  possible,  and,  as  a 
result,  have  been  able  to  carry  out  pelvimetry  in  a  satisfactory 
way.  We  always  take  three  external  measurements,  using  a  mod- 
ified pair  of  cahpers,  as  Bandelocque's  or  Schultze's  pelvimeter, 
as  follows : 

1.  The  inter s'pinous — between  the  anterior  superior  spines  of 
the  ilia — normal  25  cm.  (10  in.). 

2.  The  intercristal — between  most  widely  separated  points  of 
crests  of  the  ilia — normal  28  cm.  (11  in.). 

3.  The  external  conjugate — between  the  anterior  surface  of  the 
symphysis  pubis  and  the  depression  below  the  spinous  process  of 
the  last  lumbar  vertebra — normal  20  cm.  (8  in.). 

If  these  measurements  are  abnormal  the  following  are  taken : 

4.  The  interischial — between  the  tuberosities  of  the  ischia — 
normal  10  cm.  (4  in.). 

5.  Pubo-sacral — between  the  pubes  and  the  sacro-coccygeal 
articulation — normal  12  cm.  (5  in.). 

6.  Diagonal  conjugate — between  the  lower  edge  of  the  symphy- 
sis and  the  promontory  of  the  sacrum — normal  12  cm.  (5  in.). 

Pelvimetry  pertains  especially  to  pregnancy,  and  should  always 
be  practised  as  a  matter  of  routine  by  every  physician  during 
pregnancy.  Herman  tells  us  that  the  pelvis  can  be  measured 
more  easily  and  more  exactly  after  delivery  than  at  any  other 
time,  and  says  that  on  that  account  the  pelvis  should  be  meas- 
ured after  a  difficult  labor,  in  order  that  the  patient  might  be 
rightly  advised  and  treated  in  subsequent  pregnancies  and  labors. 
This  is  quite  right,  but  it  is  infinitely  more  important  to  have  the 
measurements  made  before  than  after  the  difficult  labor. 

DESCRIPTION  OF  PELVIMETRY 

In  taking  external  measurements  Bandelocque's  pelvimeter 
or  some  modification  of  it  is  used.  I  have  for  some  years  used 
Schultze's  instrument  and  think  there  is  none  better.     It  has  firm 


56 


PEEGKANCY 


arms  and  is  more  portable  than  most  pelvimeters.     When  closed 
it  occupies  very  little  space  in  the  satchel. 

The  patient  lies  on  her  back,  preferably  on  a  hard  table  covered 
with  a  folded  blanket,  with  her  hips  as  near  the  edge  as  possible. 


Fig.  49. — Pelvimetry;  Inter-Spinous  Measurement. 


If  she  is  especially  sensitive  as  to  exposure  she  may  be  covered 
with  a  thin  sheet.  One  can,  however,  examine  more  satisfactorily 
without  the  sheet,  and  the  exposure  required  for  the  first  three  ex- 
ternal measurements  is  so  slight  that  few  will  object  to  it.  The 
head  and  shoulders  are  slightly  elevated  and  the  knees  partially 
flexed.  The  physician  stands  beside  the  patient  (preferably  the 
right  side)  with  his  face  toward  her  head.  It  is  better  to  have 
an  assistant,  not  necessarily  a  skilled  one,  to  hold  one  or  both 
points  of  the  instrument  when  required. 

Interspinous  Measurement. — In  taking  the  interspinous  meas- 
urement the  points  of  the  two  arms  of  the  pelvimeter  are  placed 
on  the  spines  external  to  the  insertion  of  the  sartorius  muscle. 
It  is  sometimes  difficult  to  get  these  points.     According  to  the 


TELVIMETRY 


57 


German  method  the  points  of  the  two  arms  should  first  be  placed 
outside  the  iliac  crests  and  then  moved  forward  until  it  is  consid- 
ered they  have  reached  the  anterior  end  of  the  crests — that  is,  the 
external  surface  of  the  spines.  Another  method  adopted  by 
Herman  and  others  in  England  is  to  press  the  thumbs  against  the 
inner  surface  of  each  spine  so  that  the  points  of  the  caliper  shall 
not  move  inward  beyond  the  spine.  It  is  easier  for  beginners  to 
place  the  thumbs  in  these  positions  and  allow  the  assistant  to 
place  the  points  on  the  bone  just  outside  the  thumbs.  These  two 
methods  give  slightly  different  results,  the  measurement  according 


Fig.  50. — Pelvi.metry;  Inter-Cristal  Measurement. 


to  the  German  method  being,  on  an  average,  from  1  to  2  cm. 
more  than  that  by  the  other.  The  average  by  the  German  method 
is  about  26  cm. 

Intercristal  Measurement. — In  taking  the  intercristal  meas- 
urement the  points  of  the  arms  are  placed  on  those  portions  of  the 
iliac  crests  which  lie  farthest  apart.  Generally  it  is  quite  easy  to 
find  the  portions  of  the  crest  farthest  distant  from  each  other.   The 


58 


PEEGNANCY 


average  is  28  cm.  In  certain  kinds  of  deformed  pelves,  however, 
which  are  probably  always  rhachitic  in  character,  the  measurements 
between  the  spines  are  equal  to,  or  greater  than,  those  in  any  por- 
tion of  the  crests.  In  such  cases  measurement  is  made  from  the 
two  spots  on  the  crests  which  are  situated  6  cm.  posterior  to  the 
spinous  processes. 

External-Conjugate  Measurement. — In  taking  the  external  con- 
jugate the  patient  is  turned  on  her  side,  one  extremity  of  the 
pelvimeter  is  placed  upon  the  fossa  just  beneath  the  spinous  proc- 
ess of  the  last  lumbar  vertebra  and  an  assistant  holds  it  in  posi- 


FiG.  51. — Pelvimetry;  Antero-Posterior  Measurement. 


tion ;  the  other  extremity  is  placed  upon  the  anterior  surface  of  the 
symphysis  pubis  about  1  cm.  from  the  upper  border.  It  is  not 
always  easy  to  find  this  depression  beneath  the  last  lumbar  verte- 
bra. Generally,  however,  with  care  it  can  be  found  by  follow- 
ing down  the  spines  of  the  lumbar  vertebra  and  feeling  a  little 
hole  below  which  no  spinous  process  can  be  found.  If  there  is 
doubt  a  horizontal  line  is  taken  between  the  highest  points  of  the 
iliac  crests ;  the  last  lumbar  spine  lies  about  4  cm.  below  this.  Or, 
another  horizontal  line  is  taken  between  the  posterior  superior  iliac 
spines;  the  last  lumbar  spine  lies  about  2.5  cm.  above  this.  The 
average  measurement  is  20  cm.  From  this  measurement  is  de- 
ducted 9  cm.;  the  difference,  11  cm.,  will  be,  approximately,  the 
measurement  of  the  true  conjugate  diameter.  If  the  external 
conjugate  is  less  than  17  cm.  it  is  certain  that  the  true  conjugate 


PELVIMETRY  59 

diameter  is  abnormally  short ;  but  the  external  measurement  does 
not  necessarily  indicate  the  amount  of  shortening  of  the  true  con- 
jugate. When  the  external  conjugate  is  more  than  17  cm.  we 
can  not  be  certain  that  there  is  not  shortening  of  the  true  conjugate. 
However,  a  great  majority  of  deformities  included  under  the  term 
of  flat  pelvis  may  be  discovered  by  this  measurement,  and  the 
great  majority  of  universally  contracted  pelves  may  be  discovered 
by  the  three  measurements  combined. 

These  are  the  three  measurements  that  are  taken  as  a  matter  of 
routine  in  all  patients  in  the  Burnside  as  before  mentioned,  and 
they  are  the  three  measurements  which  should  be  taken  in  private 
practise.  If  there  is  no  special  deviation  from  the  normal  nothing 
further  is  done ;  if,  however,  there  is  reason  to  believe  from 
these  measurements  that  there  is  shortening  of  the  transverse,  or 
the  antero-posterior  diameter,  or  both,  further  measurements  are 
taken.  These  cause  more  exposure  of  the  patient,  the  most  impor- 
tant requiring  a  vaginal  examination.  If,  for  instance,  there  is 
reason  to  suspect  the  existence  of  a  short  conjugate  diameter  a 
vaginal  examination  should  be  considered  absolutely  necessary. 

For  internal  measurements  the  best  pelvimeter  is  the  hand  of  the 
accoucheur.  In  taking  these  measurements  the  patient  is  placed 
in  a  lithotomy  position  with  the  nates  slightly  beyond  the  edge  of 
the  table.  The  index  and  middle  fingers  of  the  left  hand  are  intro- 
duced into  the  vagina,  the  posterior  vaginal  wall  is  pushed  well 
backward,  the  elbow  is  sunk,  and  the  fingers  are  pushed  almost 
directly  upward.  If  there  is  any  shortening  of  the  true  conjugate 
it  is  generally  quite  easy  to  reach  the  promontory  of  the  sacrum. 
It  is  sometimes  possible  to  reach  the  promontory  by  this  method 
even  in  normal  pelves.  If  one  is  not  able  to  reach  the  promontory 
with  the  tips  of  the  fingers  he  may  decide  that  there  is  no  shorten- 
ing— that  is,  that  he  has  not  a  flat  or  generally  contracted  pelvis 
to  deal  with. 

The  measurement  is  taken  by  pressing  the  middle  finger  firmly 
against  the  most  easily  reached  portion  of  the  promontory,  while 
the  radial  edge  of  the  hand,  or  index  finger,  is  raised  to  the  sub- 
pubic ligament.  The  point  of  contact  with  the  latter  is  then 
marked  with  the  nail  of  the  index  finger  of  the  right  hand.  The 
distance  from  the  mark  of  the  nail  to  the  tip  of  the  finger  is  meas- 
ured with  a  small  rule  or  a  pelvimeter.  A  certain  amount  is 
deducted  from  this  to  obtain  the  length  of  the  conjugata  vera. 


60  PEEGNANCY 

One  can  not  tell  exactly  how  much,  as  the  amount  will  depend  on 
the  height  and  inclination  of  the  symphysis  pubis  and  on  the  degree 
of  elevation  of  the  promontory  above  the  symphysis.  A  safe  rule, 
however,  is  to  deduct  from  1.5  cm.  to  2  cm.  This  will  leave  10  to 
10.5  cm.  as  the  true  conjugate  diameter. 

Additional  Measurements. — The  three  external  measurements 
already  described,  together  with  the  internal  measurement  here 
referred  to,  are  practically  all  one  requires  to  take  even  in  doubtful 
cases.  Sometimes,  however,  it  is  desirable  to  get  some  informa- 
tion as  to  the  outlet.  For  such  a  purpose  it  will  be  well  to  take 
the  following  measurements : 

Inter-ischial  or  Transverse  Diameter  at  the  Outlet.  With  the 
patient  still  in  the  lithotomy  position  the  thumbs  are  placed  upon 
the  skin  over  the  ischial  tuberosities ;  the  palmar  surfaces  of  the 
thumb  are  pressed  against  the  inner  aspect  of  the  tuberosities  at 
the  level  of  the  line  running  through  the  anterior  margin  of  the 
anus.  An  assistant  then  measures  the  distance  between  the  two 
points.  The  beginner  is  very  apt  to  make  this  measurement  about 
2  or  3  cm.  too  short,  on  account  of  the  thickness  of  soft  tissue  cov- 
ering the  tuberosities. 

Pubo-sacral  Measurement.  The  end  of  the  second  finger  is 
placed  against  the  sacro-iliac  articulation  and  the  radial  edge  of 
the  hand  is  brought  in  contact  with  the  subpubic  ligament,  the 
point  at  which  the  latter  rests  against  the  hand  is  marked  by  a 
finger  of  the  other  hand.  On  withdrawing  the  hand  the  distance 
between  this  point  and  the  finger-end  is  measured.  This  measure- 
ment should  be  about  12  cm.  The  consideration  of  other  measure- 
ments, such  as  those  between  the  trochanters,  the  external  oblique 
measurements,  those  between  the  posterior  superior  spines,  and 
others,  is  omitted,  because  of  their  relatively  small  importance. 

Much  information  can  be  obtained  by  introducing  the  whole 
hand  into  the  vagina,  with  the  patient  thoroughly  anaesthetized, 
especially  after  difficult  labors.  For  instance,  we  may  get  a  pretty 
exact  knowledge  as  to  the  true  conjugate  diameter  by  ascertaining 
whether  the  forefingers  or  the  palm  of  the  hand,  or  the  closed  fist 
with  thumb  flexed  across  the  hand,  or  flattened  against  the  fore- 
finger, or  to  some  extent  extended,  will  pass  between  the  promon- 
tory of  the  sacrum  and  the  pubic  bones.  The  part  of  the  hand 
which  is  used  in  taking  the  measurements  is  across  the  narrowest 
part  of  the  brim  and  not  lying  obliquely  to  it. 


HYGIENE    AND    MANAGEMENT    OF    PREGNANCY     61 


HYGIENE  AND  MANAGEMENT  OF  PREGNANCY 

Pure  air  is  especially  necessary,  because  the  patient  "breathes 
for  two."  Her  chamber  sliould  he  well  ventilated  and  should 
contain  as  few  extras  in  the  way  of  heavy  window  curtains  and 
bed  curtains  as  possible. 

Clothing. — Woolen  garments  should  be  worn  next  to  the  skin. 
Combination  suits  (shirt  and  drawers  in  one)  are  the  most  suit- 
able. Corsets,  belts,  and  tight  garters  should  be  discarded.  Skirts 
should  be  suspended  from  the  shoulders.  For  house  wear  wrappers 
are  most  suitable. 

Diet. — No  great  change  from  the  ordinary  diet  is  required. 
The  patient  should  take  plain  food  and  omit  all  rich  foods,  pas- 
tries, hashes,  stews,  and  fancy  dishes,  and  should  also  take  plenty 
of  fluids,  especially  water. 

Constipation  should  always  receive  treatment  sufficient  to  over- 
come it.  If  regulation  of  diet  with  plenty  of  water  be  not  sufficient 
to  relieve  the  constipation,  cathartics,  such  as  Hunyadi  water, 
aloes,  salines,  or  cascara  sagrada  should  be  taken.  Cascara  sagrada 
with  maltine  is  a  good  mild  cathartic  and  is  useful  in  many  cases. 

Mammary  Glands. — These  should,  as  a  rule,  be  left  alone.  Re- 
tracted nipples  are  apt  to  cause  much  trouble,  but  endeavors  to 
pull  them  out  during  pregnancy  probably  do  more  harm  than  good. 
Efforts  to  harden  nipples  by  bathing  wath  alcoholic  solutions  and 
the  like  are  bad,  because  after  such  treatment  they  are  more  apt 
to  crack  than  if  they  are  left  alone.  If  some  application  seems 
advisable  it  is  safe  to  use  something  which  will  soften  them  or 
keep  them  soft,  such  as  lanolin,  or  castor  oil  and  bismuth  com- 
bined, equal  parts.  Efforts  to  draw  out  depressed  or  inverted 
nipples  are  dangerous,  because  they  usually  cause  irritation. 

Exercise. — A  fair  amount  of  exercise  should  be  encouraged,  but 
such  exercise  should  as  a  rule  be  somewhat  less  than  the  ordinary. 
The  patient  should  avoid  fatigue,  jars,  strains,  overreaching,  and 
lifting  heavy  weights.     Sexual  indulgence  is  more  or  less  dangerous. 

Abdominal  Bandage. — In  a  large  proportion  of  cases  pregnant 
women  should  wear  a  belly-band  or  supporting  corsets  after  the 
middle  of  pregnancy.     (Diihrssen  says  every  woman  should  do  so.) 

Importance  of  Examination. — The  importance  of  pelvimetry 
during  pregnancy  has  been  mentioned  and  its  methods  have  been 


62  PREGNANCY 

described.  Too  much  credit  can  not  be  given  to  Dr.  Whitridge 
Williams,  not  only  for  what  he  has  done  in  pointing  out  the  amount 
of  pelvic  deformity  which  exists  in  the  New  as  well  as  the  Old 
World,  but  also  for  the  practical  turn  he  has  given  to  the  subject. 
It  is  now  generally  recognized,  mainly  through  his  teachings,  that 
an  examination  of  the  patient  before  labor  should  be  a  matter  of 
routine  on  the  part  of  the  accoucheur. 

In  considering  present  opinions  as  to  the  management  of  preg- 
nancy it  is  interesting  to  note  three  distinct  features  in  what  may 
be  called  progressive  evolution  during  the  last  thirty  years : 

First.  Great  importance  was  attached  to  the  condition  of  the 
kidneys,  and  especially  albuminuria. 

Second.  A  broader  view  of  the  subject  was  taken,  and  more 
importance  was  attached  to  general  toxaemia,  of  which  albuminu- 
ria is  only  one  of  many  symptoms. 

Third.  Great  importance  was  attached  to  the  dimensions  of 
the  pelvis  and  to  many  conditions  of  pregnancy  which  may  be 
discovered  by  inspection,  pelvimetry,  and  palpation. 

Although  these  matters  are  discussed  in  various  succeeding 
chapters,  a  few  brief  rules  are  here  given  as  to  certain  points  in 
connection  with  the  management  of  pregnancy. 

Physicians  should  carefully  watch  for  and  treat  any  abnormal 
conditions  which  may  arise,  such  as  disorders  of  digestion,  head- 
aches, disorders  of  vision,  swelling  of  the  feet  and  legs,  albuminuria, 
etc.,  with  a  view  of  preventing  general  toxaemia.  They  should 
also  frequently  examine  the  urine,  to  discover  especially  the  amount 
of  urea  excreted  and  albuminuria  and  glycosuria  when  present. 
It  is  better  to  adopt  some  system  with  reference  to  the  urinary 
examinations.  One  should,  of  course,  be  guided  to  a  considerable 
extent  by  circumstances  as  they  arise,  but  it  is  well  to  carry  out 
some  rules,  such  as  the  following: 

The  urine  should  be  examined  once  a  month  from  the  end  of 
the  fifth  to  the  end  of  the  eighth  month,  and  once  a  week  or  once 
a  fortnight  during  the  ninth  month. 

A  preliminary  examination  should  be  made  in  the  eighth  month 
of  pregnancy,  about  six  weeks  before  the  expected  date  of  labor. 
As  suggested  by  Williams,  and,  as  I  have  found  preferable,  such 
examination  should  be  made  with  the  patient  in  bed  in  her  own 
home.  The  first  part  of  the  examination  is  an  inspection,  so  far 
as  one  can  make  it,  to  detect  gross  deformities  of  pelvis,  hips,  and 


HYGIENE    AND    MANAGEMENT    OF    PREGNANCY     63 

back,  and  abnormal  lios  of  the  fci'tus.  The  next  part  is  external 
pelvimetry,  and  then  internal  pelvimetry  in  the  small  proportion 
of  cases  in  which  it  is  re([uired.  After  pelvimetry  the  abdomen 
should  be  carefully  examined  by  external  palpation. 

The  Patient's  Outfit. — The  physician  should  make  careful  in- 
quiries and  give  definite  directions  as  to  articles  required  before 
labor.  The  patient  usually  has  her  outfit  at  least  partially  pre- 
pared at  this  time.     I  have  found  it  advisable  to  give  a  definite 


Fig  52. 

On  right  side,  above,  the  "guard,"  made  of  a  piece  of  butter-cloth  eight  inches 
square  folded  twice,  placed  over  vulva;  below,  piece  of  butter-cloth  twenty-one 
by  eighteen  inches;  seven  inches  from  end  (one-third  whole  length).  Cut 
inward  on  each  side  five  inches.  In  center,  below,  absorbent  cotton  placed  on 
cloth  and  edges  folded  over  it;  above,  part  containing  absorbent  cotton  folded 
twice.  On  left  side,  portion  containing  absorbent  turned  over  twice  ;  pad  com- 
plete, to  be  placed  over  guard. 

list  of  things  needed,  and  have  lately  used  a  modification  of  that 
recommended  by  Cooke,  as  follows : 

Four  abdominal  binders,  Ij  yards  long  by  |  yard  wide,  made 
of  the  cheapest  grade  of  unbleached  muslin.  This  muslin  comes 
in  a  width  of  one  yard,  and  Sf  yards  are  required  to  make  the 
necessary  number  of  binders.  They  should  be  torn  the  proper 
size  and  the  selvage  torn  off,  but  it  is  not  desirable  to  have  them 
hemmed  or  finished  in  any  other  way.  They  should  be  washed 
and  ironed  to  make  them  soft  and  comfortable.  The  cheapest 
grade  of  muslin  is  recommended,  because  the  more  expensive  and 
6 


64  PEEGNANCY 

consequently  the  heavier  quality  does  not  take  the  pins  well  and 
is  stiff  and  uncomfortable  when  in  use. 

Two  obstetrical  pads,  each  twenty  inches  square,  made  of  cheese- 
cloth stuffed  with  cotton  batting  (not  absorbent  cotton)  until  they 
are  three  or  four  inches  thick.  They  should  then  be  tacked  or 
tufted  sufficiently  to  keep  the  cotton  from  slipping,  and  are  to  be 
placed  under  the  patient's  buttocks  during  the  first  stage  of  labor. 
When  practicable  it  is  well  to  have  them  sterilized  before  use,  but 
this  is  not  absolutely  necessary  if  the  pads  are  made  with  clean 
hands  from  new  material,  as  should  always  be  the  case. 

Two  and  one-half  dozen  sanitary  or  vulvar  pads  (Snively  pat- 
tern). The  vulvar  pad  is  made  from  a  piece  of  butter-cloth  21 
inches  square.  This  is  doubled,  and  a  cut  made  extending  inward 
6  inches,  which  will  leave  7  inches  of  cloth  at  one  end  and  14 
inches  at  the  other.  Before  folding,  a  layer  of  absorbent  cotton, 
14  inches  long  and  7  inches  wide,  is  placed  in  the  center,  and  over 
this  the  butter-cloth  is  folded  from  either  side.  The  next  step  is 
to  double  the  part  containing  the  absorbent  cotton,  then  double 
again,  and  over  this  fold  one-half  of  the  piece  at  the  top,  which 
will  be  3^  inches  in  width,  and  completely  envelops  the  pad,  leav- 
ing a  stub  at  each  end,  which  can  be  slipped  under  the  binder  and 
pinned  to  keep  it  in  position.  The  patient  should  know  how  to 
make  these  pads.  As  soon  as  they  are  made  they  are  to  be  done 
up  in  packages  of  six,  and  each  package  wrapped  separately  in  a 
clean  towel  or  in  clean  white  muslin  and  laid  away  in  a  conven- 
ient place,  free  from  dust,  until  wanted. 

One  dozen  clean  towels,  preferably  old  soft  ones  without  fringe. 
These  are  to  be  pinned  up  in  another  clean  towel,  and  laid  away 
with  the  other  things.  They  are  for  use  only  about  the  patient,  and 
are  not  for  the  hands  of  the  physician  or  nurse.  If  a  sterilizer  is 
available  they  should  be  sterilized,  but  this  is  not  indispensable. 

Safety  pins.  Two  papers  of  large  and  one  of  small  in  addition 
to  those  required  for  preparing  the  bed. 

Absorbent  cotton.  One-half  pound.  Lysol,  four  ounces,  and 
bichloride  tablets.     Two  pieces  of  mackintosh  or  rubber  sheeting. 

One  slop  jar  or  pail  made  perfectly  clean  to  be  used  during  labor 
for  receiving  soiled  sponges,  towels,  and  the  like,  as  well  as  any 
solutions  or  discharges  that  can  be  directed  into  it. 

A  good  supply  of  clean  towels  (in  addition  to  the  dozen  already 
mentioned) ,  sheets,  pillow  cases,  and  nightgowns  for  the  patient 


CHAPTER  V 

PHYSIOLOGY  OF  LABOR 

Labor  is  the  process  by  which  the  foetus  and  its  appendages 
are  expelled  from  the  body  of  the  mother.  It  is  generally  rec- 
ognized that  there  are  three  factors  in  this  process:  1,  the  ex- 
pelling powers;  2,  the  body  to  be  expelled,  the  passenger ;  3,  the 
canal  through  which  it  passes,  the  passage. 

Cause  of  Labor. — Many  discussions  have  taken  place  and  many 
theories  have  been  advanced  as  to  the  determining  cause  of  labor 
with  results  so  barren  as  to  be  practically  worthless.  The  cause  is 
unknown. 

THE  EXPELLING  POWERS 

Uterine  Contractions. — The  uterine  contractions  are  the  most 
important  of  the  expelling  powers.  The  painless  contractions  of 
the  uterus  which  are  present  during  the  whole  of  pregnancy, 
gradually  gain  in  force  during  the  later  weeks  until  labor  com- 
mences, when  the  patient  becomes  conscious  of  them.  These 
contractions  are  then  accompanied  by  pains  which  become  the 
prominent  symptoms.  These  true  pains  (as  they  are  sometimes 
called)  generally  begin  in  the  back  and  pass  around  the  body  to 
the  neighborhood  of  the  pubes  or  down  the  thighs.  They  are  in- 
termittent and  come  on  at  regular  intervals.  We  may  say,  ap- 
proximately, that  the  intervals  are  about  thirty  minutes  at  the 
beginning  and  lessen  in  length  as  labor  advances.  Near  the  end 
of  the  expulsive  efforts  the  intervals  do  not  usually  exceed  one, 
two  or  three  minutes,  and  sometimes  they  disappear,  causing  the 
pain  or  the  uterine  contraction  to  be  practically  continuous.  The 
last  strong  contractions  are  called  "bearing  down  pains  "  by  the 
laity.  The  duration  of  a  pain  is  about  a  minute.  This  is  nearly 
the  average  time,  but  it  varies  from  about  half  a  minute  to  one  or 
two  minutes  until  the  final  pain,  wdiich  may  last  four  or  five  min- 

65 


66  PHYSIOLOGY    OF    LABOE 

utes.  It  not  infrequently  happens  that  for  hours  the  labor  pro- 
gresses very  slowly,  when  suddenly,  without  any  apparent  cause? 
the  pains  or  contractions  become  strong  and  long-continued  and 
the  child  is  expelled  in  a  few  minutes,  instead  of  one  or  more 
hours  as  one  might  have  expected.  Such  vagaries  in  connection 
with  uterine  contractions  and  their  results  add  much  to  the  per- 
plexities of  midwifery  practise. 

The  Value  of  the  Intermittent  Character  of  the  Pains. — When 
the  contractions  cease  to  be  intermittent,  there  is  a  condition 
called  tetanic  contraction  of  the  uterus.  This  tetanic  contraction 
stops  the  circulation  in  the  uterine  sinuses  and  in  the  placenta, 
and  shuts  oJEf  the  oxygen  supply  from  the  blood  of  the  foetus. 
As  a  result  the  foetus  sometimes  dies  in  a  comparatively  short 
time.  The  tetanic  spasm  also  causes  in  the  mother  extreme  pain, 
great  exhaustion,  sometimes  rupture  of  the  uterus,  sometimes 
death. 

While  the  pains  or  uterine  contractions  are  intermittent  the 
temporary  impediments  to  the  circulation  during  the  pains  disap- 
pear during  the  intervals  between  the  pains,  and  no  harm  comes 
to  the  foetus  or  mother. 

The  Action  of  the  Abdominal  Muscles. — The  uterine  contrac- 
tions cause  the  dilatation  of  the  lower  segment  of  the  uterus. 
When  this  dilatation  has  been  completed,  or  nearly  so,  the  action  of 
the  uterus  is  reenforced  by  certain  auxiliary  muscles.  There  are 
two  sets  of  such  muscles,  namely,  the  abdominal  muscles  and  the 
muscles  of  the  pelvis.  At  the  height  of  the  uterine  contraction 
the  woman  generally  holds  her  breath,  the  diaphragm  becomes 
fixed  and  the  contracting  abdominal  muscles  press  upon  the  ute- 
rus. In  consequence  of  these  various  forces  the  child  is  impelled 
in  the  direction  of  least  resistance — that  is,  downward  through 
the  dilated  cervix.  Generally,  the  contractions  of  the  abdominal 
muscles  are  under  control  of  the  will,  but  toward  the  close  of  the 
second  stage  they  become  more  or  less  involuntary  on  account  of 
the  reflex  factor  of  painful  distention  of  the  passage.  The  uterus 
may,  however,  expel  its  contents  without  any  assistance  from 
the  abdominal  muscles. 

The  pelvic  floor  is  at  first,  to  a  certain  extent,  an  obstacle  to  the 
progress  of  labor,  but  on  the  eve  of  expulsion  it  helps  to  push  the 
head  forward  in  the  direction  of  the  outlet;  the  muscles  of  the 
vaginal  wall  will  take  some  part  in  such  expulsion.     These  forces 


THE    EXrELLTNG    POWERS  67 

also  form  an  important  (>l(MiK'nt  in  tho  expulsion  of  the  after-com- 
ing heiitl  in  l)reech  eases,  and  in  the  expulsion  of  the  placenta. 

Influence  of  the  Nervous  System. — There  are  certain  motor  cen- 
ters which  have  more  or  less  influence  in  regulating  the  uterine 
contractions.  There  are  probably  three  such  centers,  one  in  the 
medulla,  one  in  the  lumbar  spinal  cord,  and  a  third  lying  on  the 
posterior  vaginal  fornix  and  intimately  connected  with  the  uterus. 
We  are  not  sure  that  parturition  is  altogether  a  reflex  act,  but  it  is 
chiefly  so ;  the  ordinary  labor  pains  are  probably  reflex  acts.  We 
do  not  know  what  the  stimulus  is  early  in  the  first  stage  of  labor. 
At  a  certain  time  the  contractions  which  were  previously  painless 
become  painful;  at  the  same  time  there  is  probably  some  relaxa- 
tion of  the  sphincter  fibers  at  the  lower  end  of  the  body  of  the  ute- 
rus which  permits  the  amnion,  with  its  inclosed  fluid,  to  pass  slightly 
within  the  internal  os.  This  causes  some  irritation  of  the  nerve 
endings  in  consequence  of  which  certain  stimuli  are  carried  to  the 
nerve  center  which  is  supposed  to  be  in  the  lumbar  portion  of  the 
spinal  cord.  From  this  center  the  stimuli  are  reflected  to  the  mus- 
cular fibers  of  the  uterus,  causing  those  of  the  fundus  and  upper 
segment  to  contract,  while  those  of  the  lower  segment  and  cervix 
slightly  relax.  We  make  use  of  our  knowledge  of  such  reflex  acts 
when  we  wish  to  induce- labor. 

Definition  of  Terms  used  in  Connection  with  Uterine  Contrac- 
tions.— It  is  a  matter  of  great  importance  to  have  a  clear  concep- 
tion of  certain  facts  in  connection  with  Bandl's  ring.  It  divides 
the  body  of  the  uterus  into  two  portions,  which  are  not  only  differ- 
ent from  an  anatomical  and  physiological  point  of  view,  but  are 
affected  differently  by  the  various  forces  in  action  during  labor. 
The  ring  gradually  ascends  during  labor.  At  the  same  time  the 
two  segments  are  changed;  the  one  becomes  thicker  and  shorter, 
and  the  other  becomes  thinner  and  longer.  These  are  the  main 
prominent  facts  which  one  can  easily  understand.  Frequent  ref- 
erences are  made  to  these  facts  especially  in  connection  with  tedious 
labor,  dry  labor,  prolapse  of  the  cord,  placenta  praevia,  rupture  of 
the  uterus,  expulsion  of  the  placenta,  etc. 

The  following  possible  result  furnishes  an  example  of  the  im- 
portance of  these  different  forces.  The  upper  segment  of  the  wall 
pulling  on  the  lower  is  getting  stronger,  thicker,  and  shorter.  The 
lower  segment  was  the  weaker  at  the  commencement  of  labor,  and 
when  stretched  in  this  way  is  likely  to  get  still  weaker.     Such  a 


68 


PHYSIOLOGY    OF    LABOE 


process  as  that  can  not  go  on  indefinitely  with  safety.  The  portion 
that  is  being  stretched,  thinned,  and  weakened  may  give  way. 
This  sometimes  happens,  causing  rupture  of  the  uterus. 

There  is  a  certain  amount  of  confusion  respecting  some  terms 
used  in  this  connection. 

Daldn  says :  "Contraction  means  a  shortening  of  the  muscular 
fiber  which,  when  relaxation  follows,  returns  to  its  original  condi- 
tion and  shape."  A  large  number,  if  not  most  physiologists,  give 
a  similar  definition  of  contraction. 

Horrocks  says :  ''When  a  muscle  contracts  it  is  unable  of  itself 
to  return  to  its  former  condition.     Some  other  muscle  or  force  is 


Fig.  53. — Section  of  Pregnant  Uterus  before  Retraction. 


required  to  pull  it  out  or  extend  it."     When  a  muscle  contracts 
and  then  relaxes  it  is  in  a  condition  called  "retraction." 

Galabin  says :  "  Retraction  means  the  contraction  and  shorten- 
ing of  the  uterine  muscle  not  followed  by  relaxation." 


THE    EXPELLING    POWERS  69 

These  quotations  are  from  the  writings  of  three  eminent  ob- 
stetricians of  Lontlon. 

It  may  make  things  a  httlc  more  clear  in  considering  the  three 
terms,  contraction,  relaxation,  and  retraction,  to  state  that  in  con- 
nection with  various  processes  of  labor  there  is,  normally,  no  such 


Fig.  54. — Section  of  Pregnant  Uterus  after  Retraction. 

thing  as  complete  relaxation  at  any  time.  A  muscle  may  contract 
slightly  or  completely  (so  far  as  strength  or  nerve  energy  will  per- 
mit), but  in  a  living,  healthy  body  it  probably  can  never  com- 
pletely relax.  If  the  muscular  fibers  become  completely  relaxed 
after  labor  there  could  be  no  such  thing  as  tone  or  retraction. 
There  would  be  nothing  to  prevent  a  woman  from  rapidly  bleeding 
to  death. 

It  may  be  considered,  therefore,  that  relaxation,  when  re- 
ferred to  by  physiologists  or  obstetricians,  always  means  partial 
relaxation. 

Contraction  of  a  muscular  fiber  is  the  power  to  alter  its  condi- 
tion so  as  to  actively  pull  on  its  attachments  and  thus  bring  them, 


70  PHYSIOLOGY    OF    LABOR 

or  tend  to  bring  them,  nearer  together.  A  muscle  may  contract, 
however,  without  shortening. 

Retraction  is  the  condition  of  the  muscle  which  is  produced 
by  partial  relaxation  after  active  contraction  (see  Figs.  53,  54). 
Partial  relaxation  means  that  the  contraction  of  the  muscular 
fiber  has  become  less  active  and  complete. 

The  Law  of  Polarity. — When  a  muscle  contracts  its  opponent 
relaxes.  When  the  flexors  of  the  forearm  contract  the  extensors 
relax;  when  the  extensors  contract  the  flexors  relax.  When  the 
circular  fibers  of  the  iris  contract  the  radiating  fibers  relax,  and  the 
result  is  that  the  pupil  gets  smaller ;  when  the  radiating  fibers  con- 
tract the  circular  fibers  relax  and  the  pupil  dilates.  In  the  case 
of  the  hollow  organs,  such  as  the  bladder,  heart,  uterus,  etc.,  the 
pressure  of  the  contents  of  these  cavities  acts  as  an  opponent  to  the 
contracting  fibers.  As  the  bladder  becomes  filled  the  detrusor 
fibers  tend  to  drive  the  contents  out  through  the  urethra.  At  a 
certain  time,  during  the  act  of  contraction  of  these  fibers,  the 
sphincter  relaxes,  allowing  the  urine  to  be  voided.  Similarly  the 
upper  and  lower  portion  of  the  uterus  are  opposed  to  each  other. 
The  muscular  fibers  of  the  lower  segment  and  the  cervix  uteri 
form,  practically,  a  kind  of  sphincter  muscle.  While  the  upper 
fibers  contract  these  sphincter  fibers  relax,  and  the  result  is  that 
they  are  stretched  by  the  pressure  brought  to  bear  on  the  amnion 
with  its  liquor  amnii. 

I  am,  to  a  large  extent,  using  Horrock's  explanation  of  polarity. 
He  goes  on  to  say  that  one  of  the  commonest  mistakes  made  by 
students,  when  asked  to  state  the  law  of  polarity,  is  to  say  that 
when  the  body  and  fundus  of  the  uterus  actively  contract  the  lower 
zone  and  cervix  actively  dilate.  It  is  true  they  are  often  dilated, 
"but  not  unless  there  is  something  to  dilate  them.  The  law  is  that 
when  the  body  and  fundus  contract  the  lower  zone  and  cervix  uteri 
partially  relax,  and  hence  while  in  this  state  of  partial  relaxation 
they  are  capable  of  easy  extension,  that  is,  dilatation  by  an  ex- 
tending force,  such  as  that  exerted  by  the  pressure  of  the  bag  of 
membranes;  in  other  words,  they  do  not  actively  dilate,  but  are 
passively  dilated. 

Elasticity.— This  is  a  property  which,  according  to  Matthews 
Duncan,  is  chiefly  possessed  by  the  peritoneal  coat.  It  means  the 
power  of  a  body  to  shrink  into  its  original  dimensions  after  a  force 
expanding  it  is  withdrawn.    The  peritongeum  has  no  contractility 


STAGES    OF    LABOR  71 

and  yet  it  shrinks  from  its  size,  as  it  covers  the  uterus  at  term, 
down  to  the  comparatively  small  area  of  the  outer  wall  of  the 
empty  organ,  the  pcritonoDum  over  the  upper  segment  usually  being 
without  a  wrinkle. 

The  bag  of  membranes  commences  to  assist  in  dilatation  as  soon 
as  the  OS  is  slightly  opened  by  the  contraction  of  the  upper  and 
the  stretching  of  the  lower  uterine  segment.  It  forms  a  fluid  and 
uniform  wedge,  which  becomes  progressively  more  effective  as 
dilatation  increases.  As  a  dilator  this  smooth  bag  is  more  effect- 
ive and  much  safer  than  any  solid  or  irregular  wedge,  such  as  the 
head  or  breech  of  the  foetus. 

STAGES  OF  LABOR 

The  three  stages  in  labor  are:  (1)  From  commencement  of 
labor  till  complete  dilatation  of  the  cervical  canal.  (2)  From  com- 
plete dilatation  of  the  cervical  canal  to  the  expulsion  of  the  child. 
(3)  Expulsion  of  the  placenta. 

The  division  of  labor  into  three  stages  is  convenient  and  almost 
universally  recognized  by  obstetricians.  The  first  stage  is  that  of 
dilatation  of  the  cervix,  during  which  little  or  no  propulsion  of  the 
ovum  is  taking  place.  While  this  is  the  usual  definition,  it  is  not 
correct.  It  is  really  the  stage  of  softening  and  dilatation  of  the 
cervix,  vagina,  pelvic  floor,  and  perinseum.  Normally,  rupture  of 
the  membranes  takes  place  at  or  about  the  end  of  this  stage. 
Exceptions  to  this,  however,  are  not  infrequent.  There  is  no  well- 
defined  boundary  between  the  first  stage  and  the  second  during 
which  the  foetus  is  expelled.  The  third  stage  is  more  definite. 
During  it  we  have  separation  and  expulsion  of  the  placenta  and 
membranes. 

The  average  duration  of  labor  is  eighteen  hours  for  primiparae 
and  twelve  hours  for  multiparae. 

The  Changes  in  the  Cervix. — During  the  first  stage  we  have  the 
"taking  up  of  the  cervix,"  by  which  process  the  cervical  canal 
becomes  continuous  with  the  lower  uterine  segment.  At  the  same 
time  the  os  uteri  becomes  fully  dilated,  thus  making  the  vaginal 
canal  continuous  with  the  utero-cervical  cavity. 

The  Taking-up  Process  in  Primiparae  and  Multiparae. — In  pri- 
miparae the  cervix  is  fairly  long  at  the  commencement  of  the  first 
stage,  the  external  and  internal  os  being  almost,  if  not  entirely,  in 


72  PHYSIOLOGY    OF    LABOK 

their  normal  condition.  First  the  internal  os  is  dilated,  then  the 
extravaginal  portion  of  the  cervical  canal,  then  the  intravaginal 
portion,  and  last  the  external  os. 

In  multiparse  the  external  os  is  usually  dilated  and  the  cervix 
is  somewhat  patulous  at  the  commencement  of  the  first  stage. 
During  a  vaginal  examination  the  finger  frequently  passes  easily 
into  the  cervical  canal  until  it  reaches  the  internal  os.  As  uterine 
contractions  continue  this  internal  os  dilates.  As  the  internal  os 
is  being  stretched  the  whole  canal  becomes  dilated  at  the  same 
time.  This  is  quite  different  from  the  condition  in  the  primiparae 
when  the  dilatation  travels  from  above  downward.  The  result 
is  that  as  soon  as  the  ' '  taking  up  "  of  the  cervix  has  ceased  the 
uterine  orifice  is  encircled  by  blunt,  comparatively  thick  edges 
instead  of  extremely  thinned  edges,  as  in  a  primipara. 

METHODS  OF  EXAMINATION 

Abdominal  Palpation. — We  can  ascertain  by  palpation  of  the 
abdomen  ( Jellett)  seven  important  facts : 

1.  The  presence  or  absence  of  pregnancy,  at  any  rate  from  the 
seventh  month  onward,  by  feeling  a  tumor  shaped  like  the  uterus, 
and  by  feeling  foetal  parts  within  it. 

2.  The  period  of  pregnancy,  by  mapping  out  the  height  of  the 
uterus. 

3.  The  presentation  and  position  of  the  foetus. 

4.  The  presence  of  pelvic  contraction,  which  is  by  far  the  com- 
monest cause  of  non-fixation  of  the  head.  If  we  find  that  the 
head  ballottes  freely  above  the  brim  at  a  time  when  it  should  be 
fixed,  pelvic  contraction  is  the  first  thing  to  be  thought  of. 

5.  If  the  patient  is  in  labor  the  important  points  are,  the  pres- 
ence of  pains  or  of  painless  contractions ;  and  in  the  multiparse, 
the  fixity  or  non-fixity  of  the  presenting  part. 

6.  The  course  and  progress  of  labor,  by  noting  the  descent  of 
the  presenting  part.  In  the  early  stages  the  height  of  the  chin 
above  the  symphysis  can  be  measured  in  finger-breadths.  As  labor 
advances  the  chin  approaches  the  level  of  the  symphysis  and  then 
sinks  below  it.  The  rate  of  advance  can  now  be  determined  by 
the  fourth  grip  (as  described  hereafter). 

7.  The  indications  of  threatened  rupture  of  the  uterus,  by  the 
rising  of  Bandl's  ring  upward  in  the  abdomen. 


METHODS    OF    EXAMINATION 


73 


DESCRIPTION   OF   ABDOMINAL  PALPATION 

Grips  in  Palpation. — Four  distinct  grips  or  methods  of  apply- 
ing the  hand  arc  used.  One  should  avoid  uufkio  pressure,  as  it 
causes  pain  and  contraction  of  the  abdominal  muscles  and  renders 
further  jxilpation  impossil)l(\  One  should  avoid,  also,  lifting  the 
finger-tips  off  the  abdomen — "  playing  the  piano  on  the  abdomen  " 
— as  this  also  causes  contraction  of  the  recti.  The  fingers  and 
hands  should  be  moved  gently  from  place  to  place  without  hfting 
them  off. 

1.  Funded  Grip.  The  patient  is  placed  flat  on  her  back  with 
her  pelvis  and  her  legs  extended.     The  physician  then  sits  down 


Fig.    55. — Abdominal  Palpation.     Examination  of  the  Upper  Pole  of  the 

FCETUS.       FUNDAL    GrIP. 


at  her  right  side,  about  the  level  of  the  pelvis  and  facing  her  head. 
He  next  lays  both  hands,  gently,  flat  upon  the  fundus  of  the  uterus 
and  feels  what  is  lying  there.  He  notices  the  shape  and  mobility 
of  the  part  of  the  foetus  lying  beneath  the  hands. 

2.  Umbilical  Grip.  Having  palpated  the  fundus,  the  hands 
are  moved  gently  downward  until  the  level  of  the  umbilicus  is 
reached.  By  moving  the  hands  about  the  nature  of  the  foetal 
parts  at  that  level  can  be  ascertained.  To  determine  upon  which 
side  of  the  uterus  the  back  of  the  child  lies,  the  hands  are  laid 
flat  on  either  side  of  the  uterus  and  moved  synchronously  first  to 
one  side,  then  to  the  other,  making  the  uterine  contents  move  with 
them.     By  this  means  one  notices  that  there  is  a  greater  resistance 


74 


PHYSIOLOGY    OF    LABOR 


offered  to  one  hand  than  to  the  other.  This  greater  resistance  is 
usually  on  the  side  at  which  the  back  is.  Mcllwraith  says  that  in 
examining  the  middle  zone  of  the  uterus  one  can  more  readily 


Fig.  56. — Examination  of  the  Middle  Zone.     Umbilical,  Grip. 

detect  the  back  of  the  child  by  the  following  manipulation :     One 
hand  is  placed  on  the  fundus  and  feels  that  part  of  the  uterus ; 


Fig.   57. 

The  same  as  in  Fig.  56,  except  that  the  position  of  the  foetus  is  determined  by  a 
greater  resistance  being  felt  by  the  lower  hand  over  the  back  than  over  the 
front  of  the  foetus. 


the  other  hand  presses  first  on  one  side  of  the  middle  zone,  and 
then  on  the  other.     Pressure  on  the  back  of  the  foetus  makes 


METHODS    OF    EXAMINATION 


75 


the  part  undor  the  fuiulal   hand  move.     Pressure  on  the  other 
side  of  the  middle  zone  does  not. 


1  il;.   .j8. — McIlwraith's  Maneuver. 

The  hand  at  the  fundus  presses  the  fcetus  downward  against  the  symphysis.  Then 
pressure  on  the  back  of  the  foetus  with  the  other  hand  makes  the  upper  pole  of 
the  foetus  move  under  the  hand  at  the  fundus;  pressure  over  the  front  of  the 
fcetus  does  not  do  so. 

3.  Pelvic  or  Pawlic's  Grip.     This  is  made  with  the  right  hand 
only.     The  fingers  are  sunk  into  the  false  pelvis  over  the  center  of 


Fig.  59. — Examixatki.v  ov  tiik  Lowkk  I'uli:  hv   iih;   I'u.ri-s.     Pawlic's  Grip. 


Poupart's  ligament  on  the  left  side  and  the  thumb  into  the  corre- 
sponding point  on  the  right,  and  then  they  are  approximated.    By 


76 


PHYSIOLOGY    OF    LABOR 


this  means  one  discovers  what  is  lying  in  the  pelvic  brim  and 
whether  it  is  movable  or  fixed. 


Fig.  60. — Deep  Pelvic  Grip. 


4.  Fourth  Grip.     This  is  only  necessary  when  the  presenting 
part  has  sunk  deeply  into  the  brim.     Instead  of  facing  the  patient's 


Fig.  61. — Head  Presentation,  Heart  +  below  Umbilicus. 


head  one  should  turn  so  as  to  face  her  feet.  Both  hands  are  used. 
The  tips  of  the  fingers  of  the  right  hand  are  sunk  into  the  true  pel- 
vis on  one  side,  and  the  tips  of  the  fingers  of  the  left  hand  similarly 


MECHANISM    OF    LABOR 


77 


on  the  other  side.  By  this  means  the  extent  that  the  presenting 
part  has  dcseendecl  can  1)(>  estimated. 

Examination  per  Vaginam. — By  it  can  be  determined  the  nature 
of  the  presenting  part,  the  fixity  of  the  presenting  part,  the  con- 
dition of  the  membranes,  the  size  of  the  os  uteri,  and  the  presence 
of  a  prolapsed  limb  or  card. 

Auscultation  of  Foetal  Heart. — The  heart  sounds  vary  with  the 
position  of  the  foetus.  If  the  head  is  in  the  lower  segment  the 
heart  sounds  wdll  be  heard  below  the  horizontal  umbilical  line. 
If  the  head  is  in  the  upper  segment  the  heart  sounds  will  be  heard 
above  this  line.     Generally  the  sounds  are  best  heard  at  that  side 


Fig.  62. — Breech  Presentation,  Heart  +  above  Umbilicus. 

of  the  abdomen  toward  which  the  back  of  the  foetus  lies,  excepting 
in  a  case  of  face  presentation,  in  which  they  are  generally  heard 
on  the  side  of  the  abdomen  where  the  limbs  are. 

MECHANISM  OF  LABOR 

Vertex  Presentations. — The  vertex  is  the  space  between  the 
anterior  fontanelle  and  the  posterior,  and  is  the  lowest  portion  of 
the  head  in  vertex  presentation.  Vertex  presentations  occur  in 
about  96  per  cent,  of  all  labors. 

The  following  classification  of  vertex  presentations  is  the  one 
most  commonly  used  and  most  easily  understood.  It  is  presumed 
that  the  occiput  is  the  most  important  part  to  be  considered,  and 
four  positions  of  the  occiput  are  recognized: 


78  PHYSIOLOGY    OF    LABOR 

1.  Left  occipito-anterior — L.  O.  A.  The  occiput  points  to 
the  left  foramen  ovale.  The  forehead  points  to  the  right  sacro- 
iUac  synchondrosis.  The  long  diameter  of  the  head  is  in  the 
right  oblique  diameter. 

2.  Right  occipito-anterior — R.  0.  A.  The  occiput  points  to 
the  right  foramen  ovale.  The  forehead  points  to  the  left  iliac 
synchondrosis.  The  long  diameter  of  the  head  is  in  the  left  oblique 
diameter. 

3.  Right  occipito-posterior — R.  0.  P.  The  occiput  points  to 
the  right  sacro-iliac  synchondrosis.  The  forehead  points  to  the 
left  foramen  ovale.  The  long  diameter  of  the  head  is  in  the  right 
oblique  diameter. 

4.  Left  occipito-posterior — L.  O.  P.  The  occiput  points  to  the 
left  sacro-iliac  synchondrosis.  The  forehead  points  to  the  right 
foramen  ovale.  The  long  diameter  of  the  head  is  in  the  left 
oblique  diameter.  Some  prefer  to  add  the  word  iliac  in  accord- 
ance with  French  nomenclature.  For  example,  the  first  position 
would  be  called  the  left  occipito-iliac-anterior  position  or  L.  O.  I.  A. 
We  are  told  that  there  is  no  doubt  as  to  what  this  means,  whereas 
the  term  left  occipito-anterior  might  be  applied  to  either  breech 
or  vertex  presentation. 

In  the  great  majority  of  cases  the  long  diameter  of  the  head 
is  in  the  right  oblique  diameter  of  the  pelvis — i.  e.,  the  most  frequent 
positions  of  the  occiput  are  the  left  front  and  the  right  rear,  or 
the  first  and  third  vertex  presentations,  respectively.  The  first 
position,  L.  O.  A.,  is  by  far  the  most  frequent,  and  probably 
occurs  in  about  70  per  cent,  of  vertex  presentations. 

FIRST  POSITION  OR  LEFT  OCCIPITO-ANTERIOR 

On  vaginal  examination  a  hard  round  tumor,  with  sutures  and 
fontanelles,  can  be  felt.  The  posterior  fontanelle  is  near  the  front 
of  the  pelvis ;  the  anterior  fontanelle  is  nearer  the  back  of  the  pel- 
vis. The  posterior  fontanelle  is  small  and  triangular  and  is  the 
point  where  three  sutures  meet.  Feeling  these  three  different 
sutures  may  be  our  chief  guide  to  diagnosis.  Fothergill  gives  the 
following  practical  point:  Pressing  on  the  posterior  fontanelle, 
the  angle  of  bone  which  dips  below  the  other  two  is  the  tip  of  the 
occipital  bone  whose  position  is  thus  known.  This  is,  I  believe, 
generally  correct  and  has  frequently  helped  me  to  make  a  rapid 
diagnosis  of  occipito-anterior  position.    The  anterior  fontanelle  is 


MECHANISM    OF   LABOR  79 

high  up  toward  the  mother's  back  and  can  be  felt  in  a  certain 
proportion  of  cases.  It  may  be  recognized  by  its  lozenge-Uke 
shape,  its  large  size  as  compared  with  the  posterior  fontanclle,  and 
the  fact  that  four  sutures  meet  there.  The  sagittal  suture  runs 
between  these  two  fontanelles.  If  the  finger-tip,  after  it  touches 
the  suture,  is  directed  toward  the  mother's  pubes,  it  should 
reach  the  small  fontanelle.  If  it  is  directed  backward  and  if  it 
is  pushed  far  enough,  it  will  roach  the  anterior  fontanelle.  If  it 
can  reach  the  anterior  fontanelle  very  easily,  there  is  something 
abnormal. 

The  most  favorable  time  for  examination  is  immediately  after 
rupture  of  the  membranes.  As  labor  goes  on  the  presenting  part 
becomes  oedematous  and  the  bones  lap  over  each  other  more  or 
less,  owing  to  the  molding.  It  may  thus  become  difficult  or  im- 
possible to  recognize  either  the  sutures  or  fontanelles.  Some- 
times, when  one  has  been  unable,  after  both  external  and  internal 
examination,  to  decide  as  to  presentation,  the  accoucheur  may 
obtain  valuable  information  by  placing  his  finger  or  fingers  on  the 
ear  of  the  child.  This  can  generally  be  reached  'per  vaginam;  and 
its  lobule,  pointing  to  the  occiput,  will  give  positive  evidence  as  to 
whether  the  occiput  points  to  the  front  or  the  rear. 

Flexion  with  Descent. — It  is  true  that  descent  goes  on  with  all 
the  movements  that  are  concerned  in  the  mechanism  of  labor,  but 
it  is  well  to  give  this  process  some  prominence  in  connection  with 
the  early  movement  of  flexion.  While  the  head  descends,  it  at 
the  same  time  becomes  flexed. 

The  result  is  to  substitute  the  sub-occipito-bregmatic  diameter 
for  the  occipito-frontal — that  is,  the  shorter  for  the  longer  diam- 
eter. This  allows  the  head  to  slip  easily  into  the  pelvis  when  it 
could  not  do  so  before.  This  is  illustrated  by  Fothergill,  as  fol- 
lows :  ' '  Just  as  a  man  can  get  a  hat  on  the  back  of  his  head  which 
is  too  smaU  to  fit  on  the  top  of  it,  so  a  foetal  head  can  pass  through 
a  pelvis  when  the  occiput  is  leading  which  it  could  not  traverse 
with  the  vertex  leading."  During  this  flexion  or  dipping  of  the 
occiput,  the  posterior  fontanelle  becomes  more  perceptible  to  the 
touch,  the  anterior  fontanelle  passes  backward  and  upward  out  of 
reach,  and  the  presentation  is  changed  from  vertex  to  occiput. 

Internal  Rotation. — After  flexion  the  head  advances,  with  the 
presenting  part,  the  occiput,  lying  lowest  until  it  reaches  the  pelvic 
floor.  The  posterior  part  of  this  floor  forces  the  occiput  to  turn 
7 


80  PHYSIOLOGY    OF    LABOE 

in  the  direction  of  the  least  resistance — that  is,  to  the  front  or  under 
the  pubic  arch.  Berry  Hart  thinks  that  the  great  factor  in  pro- 
ducing rotation  is  the  recoil  of  one  lateral  half  of  the  sacral  segment 
on  the  part  first  touching  it. 

Extension.  After  internal  rotation  has  been  completed  and  the 
occiput  is  turned  to  the  front  the  head  is  forced  in  a  downward 
direction.  Up  to  this  time  the  head  has  passed  downward  and 
backward ;  it  now  takes  what  may  be  called  a  sharp  curve  forward ; 
the  difference  in  direction,  which  takes  place  almost  suddenly,  in- 
volves nearly  a  right  angle.  Before  delivery  is  accomplished  there 
must  be  a  certain  amount  of  extension  of  the  head,  although  the 
chin  does  not  leave  the  sternum  until  the  greater  part  of  the  head 
has  emerged  from  the  vulvar  outlet.  It  is  exceedingly  important 
to  remember  that  this  movement  of  extension  is  not  nearly  so 
great  as  was  formerly  supposed.  I  think,  however,  that  the  cor- 
rect description  of  the  mechanism  of  delivery  varies  little  from 
that  which  was  given  about  eighty  years  ago. 

Opinions  of  the  Edinburgh  School.  The  Edinburgh  school  ap- 
pears to  think  differently,  and  as  it  has  taught  us  so  much  with 
reference  to  the  physiology  and  pathology  of  pregnancy  and  labor, 
its  views  are  worthy  of  careful  consideration.  Berry  Hart  speaks 
highly  of  Naegele's  epitome,  which  was  translated  by  Rigby  in 
1822,  and,  while  he  believes  the  account  of  the  relations  be- 
tween the  fontanelles  and  bony  pelvic  canal  are  correctly  de- 
scribed, he  thinks  that  Naegele's  description  is  inaccurate  in  other 
respects.  He  speaks  especially  of  flexion  and  extension,  which,  as 
descriptive  of  certain  movements,  are  in  his  opinion  most  mislead- 
ing terms,  while  he  does  not  profess  to  know  how  to  abandon 
them.  He  thinks  one  can  only  define  them  anew.  He  considers 
that  when  a  new  definition  is  a  contradiction  of  the  accepted  use 
of  the  term  the  student's  mystification  may  be  only  imagined. 
He  refers  to  certain  measurements  between  the  pubes  and  fundus 
as  ascertained  by  Shroeder  and  Stratz  (which  I  shall  consider 
presently),  and  to  the  study  of  frozen  sections,  as  furnishing  a 
new  theory  of  the  mechanism  of  labor  which  is  now  too  little 
taught,  but  will  become  a  basis  for  accurate  teaching  in  the 
future.  He  states  that  the  present  teaching,  as  to  its  nature  and 
nomenclature,  is  in  the  melting-pot,  and  how  it  would  emerge 
would  be  difficult  to  predict ;  the  hard-worked  student  will  cer- 
tainly suffer  most  in  this  process.     It  seems  somewhat  strange 


MECHANISM    OF    LABOR  81 

and  very  discouraging  that  a  school  so  brilKant  in  teaching 
capacity  as  that  of  lOdiuburgh,  should  bo  unable,  after  study- 
ing the  question  carefully  for  fifteen  years  or  longer,  to  do  anything 
more  than  mystify  its  students. 

Opinions  of  Sdwoeder  and  Stratz.  The  following  are  some  of  the 
clinical  facts  ascertained  by  Schroeder  and  Stratz.  These  clini- 
cians found,  by  actual  measurement  during  labor,  that  the  fundus 
of  the  uterus  is  quite  as  high  after  the  head  has  descended  to  the 
pelvic  floor  as  at  any  previous  time.  Men  in  London  and  in  Edin- 
burgh have  reached  similar  results.  It  seems  that  after  the  liquor 
amnii  escapes  uterine  contractions  act  on  the  foetus  in  a  different 
manner.  The  circular  fibers  contract  more  strongly  than  the  longi- 
tudinal, causing  the  uterus  to  become  narrower  and  longer,  the 
foetus  at  the  same  time  becoming  straightened  and  lengthened. 

We  are  told  by  the  Edinburgh  school  that  there  is  no  flexion  as 
the  head  becomes  engaged  in  the  brim,  although  it  is  true  that  dur- 
ing this  time  the  posterior  fontanelle  becomes  more  palpable.  They 
say  this  is  due,  however,  to  the  fact  that  the  occiput  dips  below  the 
sinciput.  They  also  say  the  lever  theory  of  flexion  is  incorrect,  for 
two  reasons :  first,  it  gives  a  cause  for  a  movement  which  does  not 
occur;  second,  it  is  doubtful  if  any  pressure  is  transmitted  to  the 
head  through  the  spine. 

Referring  to  the  measurements  before  spoken  of,  they  say  that 
the  fundus  does  not  sink  during  the  second  stage,  the  foetus  is  elon- 
gated and  the  curved  spine  of  intra-uterine  life  is  straightened. 
Fothergill  tells  us  that  to  understand  this  subject  it  is  necessary  to 
remember  that  the  term  flexion  was  applied  to  this  movement, 
when  the  movement  was  supposed  to  be  a  flexion  of  the  child's 
head  relative  to  the  child's  body.  Now  that  the  movement  is 
understood  to  be  only  a  movement  of  the  head  relatively  to  the 
pelvis  of  the  mother,  the  term  flexion  is  retained,  with  a  meaning 
which  does  not  belong  to  it.  This  use  of  an  old  name  with  a  new 
meaning  is  misleading,  and  it  remains  to  be  seen  how  long  the  term 
will  be  retained  in  the  nomenclature  of  the  mechanism  of  labor.  It 
is  stated  that  sectional  anatomy  shows  that  the  chin  is  touching 
the  sternum  before  the  so-called  flexion  takes  place,  and,  therefore, 
the  flexion  of  the  head  can  not  be  possible. 

I  shall  say  nothing  about  the  different  theories,  whether  they 
be  called  lever,  wedge,  or  inclined  plane;  but  I  think  that  flexion 
and  extension  do  take  place  pretty  much  in  the  way  which  has  been 


82  PHYSIOLOGY    OF   LABOE 

described  during  so  many  years.  I  do  not  see  that  proof  has  been 
brought  forward  to  show  anything  to  the  contrary. 

Flexion  and  Extension. — First,  as  to  flexion,  I  understand  that 
it  is  not  considered  possible  that  flexion  of  the  head  can  take  place 
while  the  chin  is  touching  the  sternum.  Let  a  person  who  is  sitting 
keep  his  back  in  contact  with  the  back  of  his  chair  and  bend  his 
head  until  the  chin  touches  the  sternum.  Let  him  then  keep  the 
lower  portion  of  his  back  against  the  back  of  the  chair,  and  at  the 
same  time  flex  the  upper  part  of  the  spine.  He  will  be  able  to 
bend  the  head  forward  40  to  60  degrees  without  much  difficulty. 
On  account  of  the  great  flexibility  of  the  spine  of  the  foetus  the 
head  in  the  undelivered  child  may  be  bent  still  more.  I  am  at  a 
loss  to  know,  in  connection  with  the  movement  which  takes  place 
and  which  brings  down  the  occiput,  the  difference  between  ''dip- 
ping "  and  flexion. 

It  seems  still  more  evident  that  there  must  be  extension  of  the 
head  before  its  delivery  and  also  before  it  reaches  the  vulva.  It  is 
stated  correctly  that  the  posterior  fontanelle  is  the  presenting  part 
after  internal  rotation  has  occurred,  and  that  it  is  still  the  center 
of  that  part  of  the  head  which  becomes  visible  when  it  has  descend- 
ed as  far  as  the  vulvar  aperture.  In  the  first  instance  the  posterior 
fontanelle  is  pointing  backward  toward  the  coccyx,  the  body  of 
the  child  is  held  within  the  tightly  constricting  uterine  walls,  the 
fundus  and  body  of  the  uterus  can  not  be  tilted  backward  to  any 
material  extent,  if  at  all.  Under  such  circumstances,  it  does  not 
seem  possible  for  this  presenting  part  to  change  its  direction  to  the 
extent  of  nearly  a  right  angle  without  extension  of  the  head.  It 
may  be  that  straightening  of  a  spine  which  was  before  curved  or 
flexed  causes  the  occiput  to  be  forced  forward.  If  such  movement 
of  the  head  is  not  extension,  what  is  it?  Fothergill  says  it  is  only 
slight  undoing  of  flexion.  What  is  the  difference  between  exten- 
sion and  undoing  of  flexion? 

It  is  true  that  the  fundus  uteri,  just  before  the  escape  of  the 
head,  is  higher  than  it  was  at  the  commencement  of  labor.  Such 
lengthening  of  the  uterus  is  partly  due  to  the  action  of  the  circular 
muscular  fibers,  but  also  to  the  straightening  of  the  foetal  spine 
which  probably  causes  the  extension  of  the  head. 

I  should  not  spend  so  much  time  over  this  subject  were  it  not 
for  its  vast  importance  from  a  clinical  standpoint.  Without  giving 
any  further  reasons  now,  I  shall  consider  that  the  head  can  be 


MECHANISM    OF    LABOR  83 

flexed  at  the  brim  either  by  Nature's  effort  or  by  our  own.  In 
other  words,  I  shall  consider  that  it  is  always  possible  for  Nature, 
in  her  own  way,  or  for  us,  by  pushing  on  the  occiput,  to  change  a 
vertex  into  an  occiput  presentation. 

External  Rotation. — As  soon  as  the  head  is  born  and  free  to 
move  as  it  pleases  it  recovers  its  usual  relation  to  the  shoulders. 
It  does  this  as  soon  as  the  head  clears  the  vulva,  generally  rather 
quickly.  The  right  shoulder  now  rotates  to  the  front,  and  as  the 
head  turns  with  it  the  face  is  brought  exactly  to  the  mother's  right. 
External  rotation  occurs  in  all  mechanisms  in  which  the  head  is 
born  first.  At  the  end  of  the  rotation  the  back  of  the  foetus 
always  looks  to  the  same  side  of  the  mother  as  it  did  when  the 
head  entered  the  pelvis  at  the  beginning  of  labor. 

Molding  the  Head. — In  all  labors  the  head  is  more  or  less 
changed  in  shape  while  it  is  being  driven  through  the  pelvis.  This 
is  an  important  fact  in  connection  with  the  mechanism  of  labor 
because  it  assists  in  the  adaptation  of  the  head  to  the  pelvis.  In 
vertex  presentations  the  occipito-frontal,  sub-occipito-bregmatic, 
bi-temporal,  and  bi-parietal  diameters  are  diminished,  while  the 
longest  diameter  of  the  head — that  is,  the  diameter  between  the 
chin  and  a  point  in  the  sagittal  suture  in  front  of  the  occiput — is 
increased.  The  caput  succedaneum — that  is.  the  oedematous  lump 
formed  at  the  presenting  part — forms  at  first  near  the  coronal 
suture  over  the  right  or  left  parietal  bone  as  the  foetal  head  hes  in 
the  first  or  second  position.  As  the  head  descends  this  swelling 
or  caput  moves  backward  along  the  sagittal  suture  until  it  lies 
close  to  or  slightly  over  the  posterior  fontanelle.  In  other  than 
cephalic  presentations  a  similar  swelling  develops  on  the  present- 
ing part. 

THE  OTHER  VERTEX   POSITIONS 

The  mechanism  of  delivery  in  the  three  other  vertex  positions 
differs  slightly  from  that  of  the  left  occipito-anterior  position. 

In  the  second  position,  or  R.  0.  A.,  the  left  parietal  bone  is  the 
presenting  part ;  the  sagittal  suture  is  in  the  left  oblique  diameter ; 
the  occiput  is  forced  to  the  front  after  it  reaches  the  pelvic  floor — 
i.  e.,  the  occiput  turns  from  right  to  left ;  after  the  occiput  comes  to 
the  front  the  head  is  expelled ;  after  the  expulsion  of  the  head  the 
face  turns  toward  the  mother's  left  thigh. 

In  the  third  position,  or  R.  O.  P.,  the  left  parietal  bone  is  the 


84 


PHYSIOLOGY    OF    LABOR 


presenting  part ;  the  sagittal  suture  is  in  the  right  obhque  diam- 
eter; the  occiput  generally  rotates  from  right  to  left,  and  thus 
comes  into  the  second  position,  or  O.  R.  A.,  during  its  progress; 
the  occiput  continues  to  rotate  until  it  comes  to  the  front;  after 
the  occiput  comes  to  the  front  the  head  is  expelled;  after  the 
expulsion  of  the  head  the  face  turns  toward  the  mother's  left 
thigh;  exceptionally  the  occiput  turns  to  the  rear,  causing  the 
difficult  occipito-posterior  position. 

In  the  fourth  position,  or  L.  0.  P.,  the  right  parietal  bone  is  the 
presenting  part ;  the  sagittal  suture  is  in  the  left  oblique  diameter ; 
the  occiput  generally  rotates  from  left  to  right  and  thus  comes  into 
the  first  position,  or  L.  O.  A.,  during  its  progress;  the  occiput  con- 
tinues to  rotate  until  it  comes  to  the  front;  after  the  occiput  comes 
to  the  front  the  head  is  expelled;  after  the  expulsion  of  the  head 
the  face  turns  toward  the  mother's  right  thigh;  exceptionally  the 
occiput  turns  to  the  rear,  causing  the  difficult  occipito-posterior 
position. 

The  following  table  assists  one  to  recollect  the  normal  diameters 
of  the  pelvis: 


Antero-posterior. 

Oblique. 

Transverse. 

Brim 

4  in. 
^  in. 

5  in. 

4*  in. 
5     in. 

4i  in. 

5     in. 

Cavity 

Outlet 

4i  in. 
4     in. 

The  figures  are  approximately  correct  and  easily  remembered: 
4,  4^  and  5.  The  most  important  diameter,  as  will  be  found 
when  considering  contracted  pelves,  is  the  antero-posterior  diam- 
eter at  the  brim — the  true  conjugate. 


CHAPTER  VI 
MANAGEMENT  OF  NORMAL  LABOR 

In  some  countries  it  is  considered  possible  for  any  ordinary 
woman  or  man  to  learn  how  to  conduct  a  case  of  normal  labor  in  a 
few  weeks  or  a  few  months.  The  prevailing  opinion  in  America 
is  that  it  takes  an  educated  woman  or  man  not  less  than  four  years 
to  learn  how  to  properly  conduct  a  normal  case  of  labor.  We  think 
that  no  one  can  intelligently  understand  all  about  normal  labor 
until  he  has  a  good  knowledge  of  anatomy,  physiology,  and  pathol- 
ogy, and,  in  addition,  has  gained  a  knowledge  which  will  enable  him 
to  detect  the  first  sign  or  symptom  of  abnormality  in  any  form. 

GENERAL  DIRECTIONS 

The  accoucheur  will  generally  have  seen  the  patient  before 
labor.  It  is  certainly  very  desirable  that  he  should  have  done  so 
for  many  reasons. 

It  is  quite  an  ordeal  for  a  young  practitioner  to  visit  a  patient 
in  labor  whom  he  has  never  seen  before,  and  conduct  himself  in 
such  a  manner  as  to  win  the  confidence  and  respect  of  his  patient 
and  her  friends.  A  great  deal  might  be  said  about  that  rather  use- 
ful commodity  which  is  ordinarily  called  tact.  If  Nature  has  not 
given  the  tact  it  is  not  a  very  simple  matter  to  acquire  it.  Above 
all  things  the  most  important  consideration  is  to  show  kindly  feel- 
ing toward  the  patient  under  any  and  all  circumstances.  She  is 
apt,  in  her  semi-delirium,  to  say  some  rather  uncomphmentary 
things.  The  absolute  rule  in  this  connection  should  be  never  to 
give  way  to  anger ;  always  to  be  patient  and  kind.  This  is  the  time 
when  we  should  throw  aside  all  hospitalism  and  show  the  most 
perfect  consideration  for  the  suffering  of  our  patient.  Kindly 
actions  will  certainly  bring  their  reward.  The  gratitude  of 
obstetrical  patients  forms  the  best  sort  of  capital  for  medical 
practitioners. 

85 


86      MANAGEMENT  OF  NOKMAL  LABOE 

Students  and  physicians  should  ever  cultivate  their  powers  of 
observation.  When  one  first  sees  his  patient  it  is  not  advisable  to 
ask  abruptly  about  her  symptoms.  It  is  better  to  converse  for  a 
time  on  some  ordinary  topic.  While  thus  talking,  the  physician 
should  watch  the  patient  carefully  (without,  if  possible,  appearing 
to  do  so).  He  should  see  and  hear  as  much  as  possible  and  thus 
get  a  fair  idea  as  to  her  general  condition  and  also  as  to  the  par- 
ticular symptoms  present  at  the  time.  One  can  thus  generally  ob- 
tain an  almost  exact  knowledge  as  to  the  frequency  and  severity  of 
her  pains.  But  comparatively  insignificant  circumstances,  such 
as  the  entrance  of  the  physician,  often  cause  emotional  disturb- 
ances, which  have  their  effects  on  tl^e  pains.  Questions  asked  in 
a  brusque,  abrupt  manner  may  cause  the  pains  to  be  suspended  for 
some  time. 

It  is  not  easy  to  explain  the  difference  between  the  false  pains 
which  occur  so  frequently  during  the  latter  part  of  pregnancy 
(especially  during  the  last  two  weeks)  and  the  regular  or  true 
pains  of  labor.  They  are,  in  fact,  in  many  respects  similar  in 
character.  The  true  pains,  however,  are  more  rhythmical  and 
grow  in  strength  and  frequency.  The  early  pains  are  frequently 
described  as  grinding  or  nagging.  They  are  often  very  severe  and 
cause  suffering  which  may  be  more  intense  than  that  produced 
by  the  later  and  stronger  expulsive  pains,  even  though  the  latter 
are  more  powerful  and  prolonged  than  the  early  pains.  The  pa- 
tient instinctively  aids  them  by  using  the  expiratory  muscles  as  in 
defecation.  These  bearing-down  efforts  are  partially  under  the 
control  of  the  will,  as  before  mentioned  in  connection  with  the 
physiology  of  labor.  A  method  popular  with  the  laity  is  to  have 
the  patient  push  with  her  feet  against  some  fixed  object  and  pull 
on  a  sheet  tied  to  the  foot  of  the  bed.  She  takes  a  deep  breath, 
closes  the  glottis  and  puts  all  the  expiratory  muscles  into  action, 
thus  helping  the  ordinary  uterine  contractions.  The  pains  are 
probably  caused  by  the  stretching  of  soft  parts,  especially  the 
cervix,  and  by  compression  of  nerve  filaments  through  contraction 
of  the  uterine  muscles. 

Questions. — One  naturally  soon  asks  his  patient  something 
about  her  pains.  Has  she  pains  ?  What  is  their  character  ?  Where 
are  they  and  where  were  they  first  felt  (in  the  back  or  abdomen)  ? 
How  long  do  they  last?  How  frequent?  Is  there  any  discharge 
(show)?     Without  appearing  to  have  any  doubt  on  the  subject. 


GENERAL    DIRECTIONS  87 

one  should  try  to  satisfy  himsolf  that  she  is  pregnant  and  try  to 
ascertain  whether  she  is  in  labor. 

If  the  patient  is  sitting  up  and  having  only  slight  pains  at  long 
intervals  one  may  ask  her  general  questions  as  to  her  pregnancy. 
If  a  multipara,  one  should  find  out  as  much  as  possible  about  former 
pregnancies.  Has  she  now  reached  full  term?  She  may  think 
that  she  has  or  has  not  and  will  probably  give  her  reasons  for  such 
opinions.  Inquiries  are  made  on  many  points,  and  especially  as 
to  last  menstrual  period,  and  a  calculation  is  made  as  to  the  prob- 
able date  of  labor. 

Examination. — This  is  more  or  less  distasteful  to  the  patient. 
Fortunately  it  is  considered  now  that  the  external  examination  is 
the  more  important  and  the  first  which  should  be  conducted.  It 
is  better,  as  a  rule,  not  to  mention  the  word  examination.  One 
should  not  halt  or  hesitate  in  an  awkward  sort  of  a  way,  but  simply 
ask  her  as  a  matter  of  course  to  lie  down  (unless  she  is  already  in 
the  recumbent  position) .  If  necessary  to  say  anything  tell  her  that 
you  would  hke  to  find  how  the  child  is  lying  in  the  abdomen. 

Abdominal  Palpation. — The  Dublin  method  of  examination 
has  been  described  and  indorsed.  Let  us  now  consider  the  subject 
from  the  clinical  side.  While  palpating  we  use  our  eyes  in  accord- 
ance with  rules  already  given  as  to  inspection.  The  enlargement 
of  the  abdomen  is  not  generally  symmetrical;  there  is  usually 
more  prominence  on  the  right  side  of  the  median  line  on  account 
of  the  torsion  of  the  uterus.  The  umbilicus  is  generally  protruded. 
We  notice  the  pigmentation  and  striae,  some  at  least  of  which  are 
recent,  while  others  may  be  old. 

In  former  times  the  chief  method  of  examination  was  per 
vaginam.  Many  practitioners  still  employ  this  as  their  chief 
method.  Most  of  us  now  believe  that  the  best  method  of  exam- 
ination is  the  external  by  abdominal  palpation.  In  many  cases, 
with  little  practise,  one  is  able  in  a  very  short  time  to  make  a  cor- 
rect diagnosis  of  position  and  presentation. 

Let  us  go  over  a  few  points  to  demonstrate  this.  We  shall 
suppose  that  in  placing  our  hand,  or  hands,  over  the  top  of  the 
uterus  we  find  the  breech  at  the  fundus.  This  is  generally  easily 
detected.  We  shall  also  suppose  that  on  placing  the  hands  on  the 
sides  of  the  abdomen  we  find  the  back  of  the  child  toward  the 
mother's  left  side,  but  slightly  toward  the  front.  We  may  have 
ascertained  this  much  in  less  than  a  minute.     Does  it  tell  us  any- 


88      MANAGEMENT  OF  NOEMAL  LABOR 

thing?     Yes,  it  practically  tells  us  everything.     The  child  is  lying  - 
in  the  first  vertex  position. 

In  another  case  we  find  the  breech  at  the  fundus  and  the  back 
of  the  child  toward  the  right  side  of  the  mother ;  at  the  same  time 
we  feel  small  parts  (legs  and  arms)  moving  on  the  left  side,  rather 
toward  the  front.  What  is  the  position?  The  back  of  the  child 
is  toward  the  mother's  right  side  and  inclined  to  the  rear ;  the  occi- 
put must  be  in  the  same  position — that  is,  the  occiput  is  toward 
the  right  posterior.     We  probably  have  third  vertex  position. 

In  another  case  the  woman  is  large  and  has  thick  abdominal 
walls.  On  placing  the  hands  over  the  fundus  we  are  not  quite  sure 
whether  we  feel  breech  or  head.  On  examining  the  sides  of  the 
uterus  we  think  the  back  of  the  child  is  toward  the  left  side  but 
are  not  certain.  Suddenly,  however,  we  feel  small  parts  on  the 
right  side  of  abdomen.  We  know  now  the  back  of  the  child  is  on 
the  mother's  left,  but  still  we  do  not  know  where  head  and  breech 
are.  We  examine  per  vaginam,  but  are  unable  to  reach  the  pre- 
senting part.  Pains  continue  in  the  mean  time.  After  an  interval 
of  an  hour  we  make  another  vaginal  examination.  We  reach 
something  hard  and  globular,  think  it  is  the  head.  After  moving 
the  finger  a  little  we  feel  a  suture,  but  are  not  sure  about  fonta- 
nelle ;  there  is  considerable  oedema.  However,  we  are  fairly  certain 
that  we  have  a  first  position — that  is,  left  occiput  anterior.  It  is 
certain  that  the  occiput  is  toward  the  left  side,  because  the  back 
is  in  that  position.  We  must,  therefore,  have  a  first  or  fourth 
vertex  presentation.  It  is  likely  to  be  first,  because  the  fourth  is 
very  rare.  We  feel  almost  certain  that  the  back  of  the  child  is 
slightly  toward  the  front.  However,  we  shall  suppose  there  is  a 
little  doubt.  We  examine  again  in  another  half-hour.  We  again 
reach  the  globular  body  and  find  a  suture.  Running  the  finger 
along  the  suture  toward  the  front,  we  feel  a  f ontanelle ;  it  is  small 
and  formed  by  the  junction  of  three  sutures;  that  indicates  that 
it  is  the  posterior  fontanelle.  Perhaps  we  have  found  that  one  of 
the  bones  dips  as  we  press  on  the  fontanelle.  The  bone  that  dips 
is  the  occiput,  at  least  in  the  great  majority  of  cases.  We  have 
now  verified  our  diagnosis,  both  by  external  and  internal  exam- 
ination. The  back  of  the  child  is  toward  the  mother's  left.  The 
head  is  presenting  with  posterior  fontanelle  toward  the  front. 
There  can  now  be  no  doubt.  The  child  is  lying  in  the  first  vertex 
position. 


GENERAL    DIRECTIONS  89 

Auscultation. — The  foetal  heart  sounds  are  generally  double; 
the  pulse-rate  is  between  120  and  150.  The  sound  is  heard  most 
commonly  between  the  navel  and  the  anterior-superior  iliac  spine 
on  the  left  side,  because  the  back  of  the  child  is  located  there  in 
a  great  majority  of  head  presentations.  The  area  over  which  the 
sound  may  be  heard  has  a  diameter  of  from  5  to  10  cm.  (2  to  4  in.). 

Vaginal  Examination. — When  a  vaginal  examination  is  con- 
sidered necessary,  one  should  simply  ask  for  some  hot  water  and 
make  the  hands  aseptic  or  antiseptic,  and  make  the  internal  exam- 
ination as  a  matter  of  course.  As  a  rule,  it  is  better  to  make  such 
an  examination  after  the  bladder  and  rectum  are  thoroughly 
emptied.  If  a  competent  nurse  is  present  she  is  asked  to  prepare 
the  patient.  The  accoucheur  then  leaves  the  room.  The  nurse 
should  then  thoroughly  cleanse  the  vulva  and  adjacent  parts. 
The  physician  is  probably  washing  his  hands  in  the  next  room. 
When  called  into  the  lying-in  room  he  again  cleanses  the  hands 
in  a  lysol  solution  or  something  of  that  sort.  According  to  our 
modern  ideas  as  to  cleanliness  the  correct  method  is  to  pass  in  the 
finger  by  sight.  In  doing  this  the  left  hand  draws  the  labia  wide 
apart,  so  that  the  first  contact  of  the  examining  finger  will  be  with 
the  hymen  or  the  vagina  inside  the  hymen. 

This  involves  an  exposure  so  marked  tha;t  the  sensitive  woman 
naturally  shrinks  from  it,  especially  at  this  early  stage  in  labor. 
My  custom  in  private  practise  is,  in  a  large  proportion  of  cases,  to 
examine  the  patient  lying  on  her  back  with  her  side  close  to  the 
edge  of  the  bed.  She  raises  the  knee  by  flexing  the  thigh.  I  am 
thus  able  to  put  one  hand  under  the  thigh  and  the  other  over 
the  pubes  (right  under  and  left  over,  we  shall  say) ;  while  doing 
this  the  woman  is  covered  with  a  sheet.  I  then  endeavor  with  the 
thumb  and  finger  of  the  left  hand  to  separate  the  labia  and  intro- 
duce the  finger  or  fingers  of  the  right  hand  without  any  risk  of 
picking  up  septic  matter  during  the  process. 

It  is  better  to  get  into  the  habit  of  using  either  the  right  or  left 
hand  in  examining,  according  to  the  position  of  the  patient.  It 
happens,  however,  in  a  large  majority  of  cases,  that  the  patient  and 
her  nurse  make  their  preparations  with  a  view  to  using  the  right 
side  of  the  bed. 

Our  first  aim  should  be  to  reach  the  os  and  note  its  form,  con- 
sistence, and  degree  of  dilatation.  Sometimes  the  external  hand 
may  depress  the  fundus  in  such  a  way  as  to  bring  the  head  within 


90      MANAGEMENT  OF  NOKMAL  LABOE 

more  easy  reach.-  If  partial  dilatation  has  taken  place  the  pre- 
senting part  is  examined.  The  examination  is  made  between  the 
pains,  so  as  to  avoid  the  risk  of  too  early  rupture  of  the  membranes. 
Feeling  a  parietal  bone,  then  a  suture,  and  then  one  or  both  fon- 
tanelles  will  probably  give  sufficient  information  as  to  the  presen- 
tation. Then  the  finger  is  passed  around  the  pelvis  to  discover 
any  abnormality  of  shape.  An  effort  is  made  to  find  the  prom- 
ontory of  the  sacrum  with  the  tip  of  the  middle  finger.  If  this  can 
be  reached  easily  one  may  be  practically  certain  that  there  is  some 
abnormal  condition — that  is,  a  short  conjugate  diameter  with 
probably  a  flat  pelvis.  One  should  notice  whether  the  vagina  is 
normal,  whether  its  walls  are  relaxed,  whether  there  is  a  proper 
secretion  of  mucus,  or  a  dry  and  hot  condition ;  also  the  condition 
of  the  perinsBum  as  to  rigidity. 

If  the  perinaeum  is  rigid,  the  vagina  constricted,  the  os  closed, 
with  no  secretion  of  mucus  (show),  the  patient  is  not  in  labor.  If 
the  perinaeum  is  soft  and  dilatable,  the  vagina  soft  and  dilatable, 
the  cervix  fully  dilated,  perhaps  to  such  an  extent  that  one  can  not 
detect  it  at  all,  the  patient  has  completed  the  first  stage  of  labor — 
that  is  to  say,  the  parts  are  prepared  for  the  passage  of  the  child. 

Preparation  of  the  Patient. — The  patient,  when  near  term, 
should  wash  carefully  with  soap  and  water  the  vulvar  region  at 
the  time  of  her  daily  bath.  When  labor  is  expected  the  nurse 
should  clip  the  ha,ir  about  the  vulva  as  closely  as  possible  with  a 
pair  of  scissors.  This  assists  in  the  prevention  of  sepsis  and  the 
discomfort  which  is  caused  by  the  clotting  of  lochia  upon  the  hair. 
Before  the  first  examination  is  made  in  labor  the  vulva  and  neigh- 
boring parts  should  be  thoroughly  scrubbed  with  soap  and  water 
for  not  less  than  five  minutes.  The  majority  of  obstetricians 
recommend  the  use  of  a  nail-brush.  I  do  not  insist  on  this  always, 
but  I  do  insist  that  a  nail-brush  when  used  should  always  be  new. 
An  antiseptic  pad  soaked  in  lysol,  or  other  antiseptic  solution, 
should  then  be  placed  over  the  vulva.  A  pad  of  this  sort  should 
be  changed  somewhat  frequently,  and  the  vulva  should  be  thus 
protected  as  far  as  possible  until  the  labor  is  completed. 

.  Some  obstetricians  insist  that  the  vagina  should  then  be 
douched  with  an  antiseptic  solution.  This  is  quite  unnecessary, 
unless  there  is  some  special  indication  for  it,  such  as  the  presence 
of  gonorrhoea  or  some  condition  which  causes  an  offensive  dis- 
charge.    In  administering  a  douche  before  labor  one  should  never 


GENERAL    DIRECTIONS  91 

use  a  bichloride  solution,  because  it  corrugates  the  tissues,  hinders 
to  some  extent  the  descent  of  the  presenting  part,  and  renders  the 
tissues  more  liable  to  be  lacerated ;  and  to  formalin  these  objec- 
tions apply  even  more  strongly.  I  think  the  best  solution  for 
antepartal  douching  is  a  1  or  2  per  cent,  of  lysol. 

Preparations  during  Labor  by  Nurse  and  Doctor. — The  nurse 
should  make  arrangements  to  have  water  boiling  continuously 
during  labor.  For  such  purpose  the  water  may  be  heated  in  an 
ordinary  clothes-boiler  or  preserving-kettle  or  a  teakettle.  The 
advantage  in  using  a  boiler  or  large  preserving-kettle  is  that  one 
may  introduce  any  instruments,  such  as  forceps,  etc.,  for  steri- 
lizing purposes.  The  nurse  should  also  empty  some  of  the  water, 
after  it  has  been  boiling  for  a  certain  time,  say  fifteen  minutes, 
into  some  receptacle,  such  as  an  ordinary  pitcher,  and  allow  it  to 
cool,  at  the  same  time  covering  the  mouth  of  the  pitcher  with  a 
sterilized  towel.  One  or  two  such  pitchers,  filled  with  sterilized 
water,  should  be  placed  in  the  lying-in  room  to  be  used  for  cooling 
certain  solutions,  as,  for  instance,  normal  saline  solutions  for  sub- 
cutaneous injection. 

The  nurse  should  also  have  a  sufficient  supply  of  receptacles  for 
her  solutions.  Ordinary  wash-basins,  soup-plates,  or  platters,  will 
suffice.     The  following  will  be  sufficient  for  any  ordinary  case : 

Wash-basin  for  general  purposes  and  especially  preliminary 
hand  washing. 

Wash-basin  for  lysol  solution,  2  per  cent. 

Wash-basin  for  bichloride  solution,  1-1000. 

Soup-plate  for  catheter,  artery  or  tongue  forceps,  and  rub- 
ber tubing  with  bulb  attached,  in  lysol  solution.  2  per 
cent. 

Soup-plate  for  twenty  small  cotton  swabs,  in  lysol  solution, 
2  per  cent. 

Soup-plates  for  cotton,  silk,  or  bobbin,  to  tie  the  cord,  and 
cord  scissors,  in  lysol  solution,  2  per  cent. 

Large  soup-plate,  or  small  platter,  for  receiving  the  placenta. 
This  should  be  covered  by  a  towel  taken  from  a  lysol  solu- 
tion, 2  per  cent. 

Teacup  for  boric-acid  solution  for  babe's  eyes. 

Most  of  these  may  be  placed  on  a  table  at  one  side  of  the  room. 
The  lysol  solution  in  the  wash-basin  should  be  placed  close  at 


92 


MANAGEMENT  OF  NOEMAL  LABOE 


hand  for  the  use  of  the  operator,  especially  during  the  birth  of  the 
child  and  the  expulsion  of  the  placenta. 

The  doctor  should,  in  good  time,  put  his  instruments,  including 
the  forceps,  in  a  towel  and  have  them  sterilized  with  boiling  water. 
As  before  intimated,  this  may  be  easily  done  by  placing  them  in 
a  closed  boiler  or  preserving-kettle  containing  the  boiling  water. 


Fig.  63. — Room  Prepared  for  Labor. 


After  they  are  sterihzed  the  different  smaller  instruments  should 
be  placed  in  the  plates  as  indicated.  The  forceps  should  be 
wrapped  in  a  sterilized  towel. 


THE   ONSET   OF   LABOR 

Diagnosis. — It  is  difhcult  to  lay  down  rules  as  to  the  diagnosis 
of  the  onset  of  labor,  as  it  is  impossible  with  our  present  knowl- 
edge to  name  any  definite  set  of  symptoms  which  will  indicate 
with  certainty  the  exact  time  of  the  commencement  of  labor. 

While  making  an  examination  one  may  be  able  to  determine 
that  the  presenting  part  is  low  down.  Although  under  such  cir- 
cumstances the  OS  is  but  slightly  or  not  at  all  dilated,  one  might 
consider  that  labor  had  either  commenced  or  was  about  to  do  so. 
This,  however,  would  not  always  be  correct,  because  under  ordi- 


GENEEAL    DIRECTIONS  93 

nary  circumstances  the  presenting  part  is  almost  invariably  low 
down  in  primipara3  one  to  two  or  three  weeks  before  the  onset  of 
labor,  whereas  in  multipara)  the  presenting  part  may  remain  higher 
up  until  the  labor  is  well  advanced.  Excessive  cervical  secretion 
(the  so-called  "show"),  together  with  pains,  furnishes  the  most 
certain  sign  of  the  onset  of  labor.  Unfortunately,  however,  even 
the  combination  of  pains  and  show  does  not  furnish  a  positive 
indication.  Sometimes  such  excessive  cervical  secretion  is  not 
immediately  followed  by  labor,  and  occasionally  labor  sets  in 
without  it. 

Regular,  rhythmical  contractions  gradually  increasing  in  fre- 
quency and  severity,  progressive  dilatation  of  the  os,  together  with 
the  copious  blood-stained  discharge,  indicate  with  certainty  that 
the  patient  is  in  labor.  We  have  been  told  that  even  these  three 
concurrent  signs  are  not  necessarily  followed  by  progressive  labor. 
For  instance,  "  in  a  patient  suffering  from  contracted  pelvis,  where 
labor  was  induced  by  the  introduction  of  De  Ribes's  bag,  contain- 
ing 16  ounces  of  water,  through  the  cervix  without  rupture  of  the 
membranes,  regular  pains  ensued  until  full  dilatation  of  the  os. 
The  bag  was  then  expelled,  the  pains  gradually  ceased  and  twelve 
hours  afterward  the  os  had  contracted  down  to  the  size  of  a  two- 
shilling  piece.  Twenty-four  hours  afterward  the  os  just  admitted 
two  fingers  with  difficulty.  The  bag  was  again  introduced  and  the 
membranes  artificially  ruptured,  when  the  bag  was  expelled.  Labor 
terminated  naturally  "  (Mathew,  Queen  Charlotte  Hospital). 

It  is  quite  true  that  when  dilatation  of  the  os  has  been  produced 
by  artificial  stretching  it  may  be  followed  by  more  or  less  contrac- 
tion after  the  stretching  process  is  stopped  and  thus  prevent  the 
progress  of  labor  for  a  more  or  less  indefinite  time.  This  does  not 
contravene  the  clinical  fact  that  regular  pains,  show,  and  natural 
dilatation  of  the  os  indicate  positively  the  condition  of  labor. 

We  are  often  asked  by  the  patient  or  nurse  to  name  the  sign 
which  will  indicate  the  necessity  or  advisability  of  summoning  the 
doctor.  It  is  easy  and  correct  to  say  that  as  soon  as  the  patient 
has  regular  pains  similar  to  those  which  have  been  already  de- 
scribed as  true  pains,  together  with  a  show,  the  patient  should  be 
considered  in  labor.  The  physician  should  try  to  explain  the  differ- 
ence between  the  so-called  true  pains,  which  generally  radiate  from 
the  back,  and  the  false  pains,  which  are  more  apt  to  appear  in  the 
front,  and  are  generally  due  to  colic.     It  is  safer,  however,  to  have 


94      MANAGEMENT  OF  NOEMAL  LABOE 

the  patient  or  nurse  consider  that  the  doctor  should  be  summoned 
when  the  patient  has  anything  hke  severe  pains,  whether  com- 
mencing in  the  back  or  front  and  whether  accompanied  or  not  by 
excessive  cervical  secretion  and  dilatation  of  the  os.  The  follow- 
ing rules  are  useful  for  the  nurse  and  young  accoucheur : 

I.  Rules  for  the  Nurse.     Send  for  the  Doctor — 

a.  When  there  are  pains  with  excessive  cervical  secretion — 

''show"  (almost  certain). 

b.  When  there  is  ''show  "  even  with  doubt  as  to  character 

of  the  pains. 

c.  When  there  are  fairly  severe  and  regular  pains,  especially 

when  they  radiate  from  the  back. 

n.  Rules  for  the  Doctor. 

a.  When  there  are  rhythmical  contractions  (pains)  gradu- 

ally increasing  in  frequency,  show,  and  dilatation  of 
the  OS,  with  or  without  protrusion  of  the  bag  of  mem- 
branes, the  patient  is  in  labor. 

b.  When  the  contractions  are  not  strong  nor  frequent  and 
the  OS  is  only  dilated  to  the  size  of  a  twenty-five  cent 
piece  the  patient  is  in  labor  but  not  far  advanced.  One 
may  probably  leave  her  for  an  hour  or  two,  especially 
if  a  primipara. 

c.  When  the  contractions  are  strong  or  fairly  strong  and  fre- 

quent and  the  os  dilated  to  the  size  of  a  fifty-cent  piece, 
the  patient  is  probably  well  advanced  in  labor.  It  is 
not  safe  to  leave  her. 

The  Obstetrical  Satchel. — No  one  has  been  able  as  yet  to  fur- 
nish an  obstetrical  satchel  which  is  satisfactory  in  all  respects. 
The  ordinary  leather  bag  can  not  be  kept  aseptic  and  for  this 
reason  some  have  used  metallic  cases.  These,  however,  are  heavy 
and  clumsy.  The  so-called  aseptic  midwifery  bag  with  removable 
linings  ceases  to  be  aseptic,  as  a  rule,  when  it  is  handled.  Most 
surgeons  and  obstetricians  continue  to  carry  their  instruments  in 
leather  satchels  or  bags.  For  obstetrical  purposes  I  prefer  the 
leather  cabin  bag,  16  or  18  inches  long.  The  articles  placed  in 
the  bag  should  be  protected  by  proper  coverings ;  the  best  material 
for  such  being  metal,  glass,  or  washable  linen  or  cotton. 


GENERAL    DIRECTIONS  95 

The  following  articles  are  rcconuiu'iHlcd  fcjr  the  satchel: 

Axis-traction  forceps. 

Pelvimeter. 

Hypodermic  syringe  with  morphine  and  stryclniine  tablets  in  a  case. 

Artery  forceps  which  may  be  used  as  a  needle-holder. 

Needles  in  metal  case. 

Scissors. 

Double  tenaculum. 

Uterine  dressing  foi'ceps. 

Posterior,  or  Sims's  si)e('ulum. 

Hollow  needle  for  hypodermoclysis. 

Nail-brush. 

A  soft  rubber  tube  with  bulb  attached. 

Catgut,  silkworm  gut,  and  silk  in  hermetically  sealed  bottles  or  tubes. 

Ergot. 

Lysol  or  carbolic  acid. 

Tablets  of  corrosive  sublimate. 

Antiseptic  powder. 

Tablets  of  chloral. 

Chloroform. 

Mixture  of  chloroform  and  ether  (equal  parts  by  bulk). 

Sealed  packet  of  iodoform  gauze  (5  per  cent.). 

Gravity,  or  Davidson's  syringe. 

Glass  or  metal  douche  tube. 

Soft  rubber  or  glass  catheter. 

Buckmaster's  shng  or  Robb's  leg-holder. 

White  hnen  coat  or  operating  gown. 

Rubber  gloves. 

The  Accoucheur's  Dress. — Very  few  modern  surgeons  think  of 
operating  either  in  hospital  or  private  practise  without  wearing  a 
fresh  gown  or  apron  of  some  sort.  Obstetricians  do  not  so  com- 
monly prepare  themselves  in  this  way ;  many  of  them  simply  take 
off  their  coats  and  roll  up  their  sleeves  within  sight  of  the  patient, 
and  look  sometimes  as  if  preparing  for  a  fight.  The  sight  of  a  big, 
muscular  doctor  thus  preparing  to  treat  a  poor,  delicate,  little 
woman,  generally  causes  fear  and  trembling.  On  the  other  hand, 
I  can  not  say  that  I  admire  a  butcher's  apron,  nor  the  nightgown 
such  as  old  Smellie  used  to  wear  a  hundred  and  fifty  years  ago, 
but  prefer  a  plain  white  coat  with  short  sleeves,  buttoned  either 
in  front  or  behind.  Let  the  physician  choose  what  he  likes,  how- 
ever, so  long  as  it  is  clean,  but  he  should  prepare  himself  in  an 
adjoining  room,  not  in  the  patient's  bed-room.     This  is  especially 


96      MANAGEMENT  OF  NOKMAL  LABOR 

necessary  if  he  uses  overalls  as  well  as  a  gown.  If  he  has  nothing 
better  let  the  nurse  fasten  over  his  waistcoat,  shirt  or  suspenders, 
a  large  towel  to  take  the  place  of  an  apron,  and  also  a  smaller  towel 
around  one  or  both  forearms. 

The  Lying-in  Chamber. — One  should  choose,  if  possible,  the 
most  suitable  room  in  the  house.  It  should  be  large,  airy,  and  re- 
moved as  far  as  possible  from  the  noise  of  the  house  and  the  streets. 
There  is  always  a  certain  amount  of  danger  when  the  room  is  close 
to  a  water-closet,  or  when  there  is  in  it  a  sink  or  basin  with  waste 
pipe  passing  through  it.  All  unnecessary  furniture  and  heavy  cur- 
tains should  be  removed. 

The  Bed. — It  is  better  to  have  a  bed  which  is  narrow  and  fairly 
high,  but  in  the  majority  of  cases  one  will  have  to  take  the  bed  as 
he  finds  it.  A  soft  feather-bed,  however,  is  decidedly  objection- 
able. We  scarcely  see  such  a  thing  in  our  larger  cities,  but  in  many 
country  districts  a  feather  bed  is  highly  prized.  When  it  is  present 
on  the  obstetrical  bed  it  should  be  removed.  Sometimes  a  poor 
mattress  on  weak  springs  is  almost  as  objectionable  as  the  feather- 
bed, especially  where  interference  is  required,  as,  for  instance, 
in  the  management  of  breech  cases  and  forceps  delivery.  Under 
such  circumstances  the  placing  of  one  or  two  boards  immediately 
under  the  mattress — that  is,  over  the  springs — improves  the  con- 
dition of  the  bed  very  materially. 

Two  pieces  of  mackintosh  or  rubber  sheeting — one  full  size  of 
bed,  the  other  half  size — are  required.  The  rubber  sheeting  is  more 
expensive,  but  if  it  is  thoroughly  cleaned  after  labor  it  may  be  used 
for  two  or  three  years  on  the  infant's  bed  (Cooke).  It  is  a  good 
plan  to  use  a  large  mackintosh  and  a  small  piece  of  rubber  sheeting. 

The  large  mackintosh  is  used  chiefly  to  protect  the  mattress. 
The  under  blanket,  bolster  and  sheet  are  used  to  make  the  bed 
comfortable.  The  smaller  mackintosh  or  piece  of  rubber  sheeting 
with  the  draw  sheet  is  used  to  protect  the  bed  from  the  copious  dis- 
charges which  take  place  during  the  second  and  third  stages  of 
labor  and  is  so  arranged  that  it  can  be  easily  removed  from  the  bed 
after  the  completion  of  labor.  Some  of  our  obstetricians  use  the 
Kelly's  pad  or  something  similar  to  it,  but  I  do  not  recommend 
its  use  in  ordinary  private  practise,  because,  in  the  first  place,  it  is 
too  bulky  for  a  satchel  such  as  I  have  described,  and  in  the  second 
place,  it  is  difficult  to  keep  it  aseptic.  It  is  also  very  liable  to  become 
displaced  and  interfere  with  labor,  more  especially  if  forceps  are 


GENERAL    DIRECTIONS  97 

being  applied,  with  the  patient  on  her  side.  There  are,  however, 
specially  made  pads  of  other  material,  such  as  wood  wool,  cotton- 
batting,  etc.,  which  are  very  convenient. 

Antisepsis  and  Asepsis. — ^Every  physician  should  carry  out  cer- 
tain definite  rules  as  to  antisepsis  and  asepsis.  His  constant  aim 
should  be  to  have  his  patient,  her  surroundings,  and  himself  per- 
fectly clean.  He  may  do  that  perhaps  with  soap  and  hot  water, 
and  may  call  his  methods  aseptic.  If  so,  I  shall  not  object,  al- 
though I  may  say  that  both  soap  and  hot  water  are  to  some  extent 
antiseptic  or  germicidal.  I  prefer,  however,  the  use  of  stronger 
antiseptics  for  certain  purposes.  If  called  upon  to  recommend 
only  one  antiseptic  for  midwifery  practice  I  should  certainly  choose 
lysol.  A  few  years  ago  I  should  have  said  carbolic  acid.  Either 
of  these  is,  in  a  sense,  unobjectionable  if  not  used  in  poisonous 
doses,  while  corrosive  sublimate,  as  already  stated,  is  sometimes 
injurious,  especially  when  used  immediately  before  or  during  labor. 

After  using  carbolic  acid  for  years  I  tried  lysol,  but,  finding  its 
odor  somewhat  unpleasant,  I  went  back  to  carbolic  acid.  After 
using  this  for  a  time  and  carefully  comparing  results,  I  have  again 
chosen  lysol  as  the  best  all-round  antiseptic  for  obstetrical  purposes. 
As  compared  with  carbolic  acid  it  is  less  corrosive,  less  poisonous, 
more  readily  miscible  with  water,  less  likely  to  injure  the  hands, 
and  above  all  other  comparative  considerations,  is  decidedly  soapy 
in  character ;  at  the  same  time  lysol  is  probably  quite  as  destructive 
of  microbes  as  carbolic  acid.  I,  however,  always  carry  bichloride 
tablets  and  use  them  especially  for  cleansing  the  external  parts 
after  labor. 

While  I  advise  and  use  both  antiseptic  and  aseptic  methods,  I 
quite  agree  with  Di.ihrssen  that  "the  introduction  of  asepsis  with- 
out antisepsis  into  midwifery  is  a  mistake,  since  the  field  of  opera- 
tion in  midwifery  is  a  germ-containing  one." 

For  ordinary  obstetrical  purposes  make  the  antiseptic  solutions 
in  the  following  proportions :  Lysol  solution,  1  or  2  in  100,  or, 
roughly  speaking,  one  or  two  teaspoonfuls  to  the  pint,  supposing 
the  ordinary  teaspoon  to  contain  about  80  minims ;  bichloride  solu- 
tion, 1  to  1000 — that  is,  one  7^  grain  tablet  to  a  pint. 

Lubricants. — One  should  not  use,  as  a  lubricant  for  the  finger, 
any  vaseline,  oil,  etc,  that  may  be  in  the  house.  One  should  also 
avoid  the  so-called  medicated  lubricants,  because  many  of  them 
are  absolutely  worthless  and  frequently  harmful.     The  physician. 


98      MANAGEMENT  OF  NOEMAL  LABOR 

after  anointing  the  finger  or  fingers  with  one  of  these  lubricants, 
may  carry  pathogenic  germs  into  the  parturient  canal  and  leave 
them  there  so  protected  that  they  can  not  be  washed  away  by  the 
liquor  amnii.  The  most  common  of  these  antiseptic  lubricants  is 
probably  carbolized  vaseline,  which  has  been  proved  to  be,  in 
certain  cases,  a  good  culture  medium  for  the  bacteria,  the  vase- 
line protecting  the  germs  from  the  action  of  the  carbolic  acid.  It 
has  been  pointed  out  by  some  obstetricians  that  the  application  of 
a  lubricant  to  the  finger  adds  an  element  of  safety  when  there  are 
sores  on  the  vulva  or  vaginal  wall.  That  is  true  to  a  certain  extent, 
but  when  such  sores  are  present  one  should  always  wear  rubber 
gloves. 

FIRST  STAGE  OF  LABOR 

Importance  of  Enemas. — The  patient  is  now  in  her  lying-in 
room;  she  has  been  properly  prepared  for  labor.  For  weeks  or 
months  we  have  been  trying  to  get  her  into  good  condition.  We 
have  especially  looked  after  the  liver  and  kidneys  and  have  kept 
the  bowels  open.  What  next?  Let  the  nurse  administer  an  en- 
ema. "There  is  no  necessity  for  that,  Doctor,"  the  nurse  may 
say,  "because  the  patient  has  already  had  two  evacuations  this 
morning,  in  fact  she  almost  has  diarrhoea."  Make  no  difference 
on  that  account.  In  all  cases  one  should  insist  on  the  adminis- 
tration of  an  enema.  A  short  time  ago  I  had  a  somewhat  tedious 
labor.  I  had  looked  after  my  patient  carefully  during  pregnancy 
and  had  one  of  my  best  nurses.  She  had  looked  after  everything 
required  for  the  labor,  as  I  supposed.  I  found  it  necessary  to 
apply  the  forceps,  and,  on  using  traction,  some  soft  faeces  emerged 
from  the  anus.  "Didn't  you  administer  an  enema,  Miss  S.?"  I 
asked.  "No,  Doctor,  it  was  not  necessary;  her  bowels  were  well 
moved  this  morning. ' '  The  extraction  was  somewhat  slow  and  a 
plentiful  supply  of  the  softened  faeces  came  constantly  during  the 
process.  The  nurse  was  kept  busy  using  towels  in  the  necessary 
cleansing  process,  and,  while  doing  so,  I  hope  learned  the  lesson 
which  I  supposed  she  had  been  taught  some  years  ago  in  our 
Training  School  for  Nurses. 

The  following  morning,  on  going  to  the  Burnside,  I  asked  Miss 
McKellar  when  she  considered  an  enema  should  be  administered 
before  labor.  She  said,  in  all  cases.  "  But,"  I  asked,  "what  will 
you  do  if  the  patient  already  has  diarrhoea ?  "     "In  any  case  we 


FIEST  STAGE  OF  LABOR  99 

administer  the  enema.  Is  that  not  what  you  teach,  Doctor?" 
"Yes,"  I  said,  "but,  notwithstanding  what  you  and  I  teach,  some 
of  your  nurses  do  not  understand  what  they  should  do  under  such 
circumstances." 

It  happens  that  the  escape  of  fsccal  matter  in  these  so-called 
diarrhoea  cases  is  frequently  the  worst  sort  one  meets  with.  Such 
an  accident  is  not  simply  unpleasant,  it  is  also  dangerous,  because 
it  interferes  sadly  with  asepticism  and  it  is  often  exceedingly  hu- 
miliating to  a  patient.  This  is  one  of  the  small  points  in  connec- 
tion with  the  conduct  of  labor  which  should  be  considered  impor- 
tant. When  an  enema  has  been  administered  early  in  a  prolonged 
first  stage  it  is  well  to  have  a  second  enema  administered  after  an 
interval  of  twelve  to  fifteen  hours.  Some  women  object  strongly 
to  the  administration  of  an  enema,  but  if  one  explains  to  such 
how  the  enema  is  likely  to  prevent  unpleasant  accidents  she  will, 
as  a  rule,  readily  withdraw  her  objections. 

Directions  for  the  Nurse  after  Labor. — Definite  directions  are 
given  to  the  nurse  with  reference  to  the  after-treatment  of  the 
patient,  especially  for  four  days.  If  not  certain  as  to  her  methods 
the  directions  should  be  put  in  writing.  Why  specify  four  days? 
Certainly  not  because  I  wish  the  nurse  to  become  careless  at  the 
end  of  four  days.  But  the  rents  and  tears  in  the  parturient  tract 
are  covered  with  healthy  granulations  in  three  or  four  days.  Such 
a  granulating  surface  is  practically  non-absorbent. 

Cases  of  Emergency. — At  an  examination  a  few  years  ago  I 
asked  a  graduating  class:  What  should  the  obstetrician  do  when 
he  came  into  the  room  while  the  child  was  being  born?  Some  in 
their  answers  gave  full  directions  as  to  the  preparation  of  the 
hands  before  touching  the  mother  or  babe.  I  need  scarcely  point 
out  the  absurdity  of  such  a  course  of  action.  In  such  a  case  one 
must  help  the  patient  and  child  at  once.  Receive  the  babe  in  one 
hand  and  place  the  other  over  the  uterus,  then  clean  the  hands 
thoroughly  before  touching  the  vulva  or  vagina.  One  may  be 
called  upon  to  conduct  a  case  of  labor  without  any  of  the  ordinary 
instruments  or  antiseptics  recommended  for  the  satchel;  in  such 
a  case  he  should  aim  at  doing  aseptic  work.  This  is  not  difficult 
to  do  in  any  house,  especially  if  soap,  hot  water,  and  clean  towels 
can  be  obtained. 

Introduction  of  Hand  into  Uterus. — The  accoucheur  should 
wash  well  the  hand,  wrist,  and  arm  before  introducing  the  hand 


100  MAIsTAGEMENT    OF    NORMAL    LABOR 

into  the  uterus.  I  presume  that  the  hands  have  been  washed 
before  this  and  also  that  the  vulva  and  adjacent  parts  have  been 
carefully  cleansed.  Such  directions,  of  course,  are  common  as  to 
midwifery  practise.  A  great  many  add,  however,  that  an  intra- 
uterine douche  should  always  be  administered  after  the  hand  has 
been  introduced  into  the  uterus.  I  have  never  given  any  such 
recommendation  nor  adopted  any  such  rule  for  myself.  In  the 
first  place,  certain  dangers  are  always  associated  with  intra-uterine 
douching.  In  the  second  place,  there  is  no  necessity  for  such 
procedure  after  introducing  a  clean  hand  into  the  uterine  cavity. 

Prognosis. — The  physician,  after  having  made  his  examination 
in  the  ways  already  indicated,  will  have  reached  certain  conclu- 
sions. He  will  have  found  the  condition  favorable  or  unfavorable, 
as  the  case  may  be,  and  will  have  formed  some  idea  as  to  the 
progress  of  labor.  He  will  be  asked  certain  questions  of  which  the 
following  is  probably  the  most  common :  ' '  Is  everything  right  ? ' ' 
The  patient  or  her  friends,  in  asking  such  a  question,  mean,  "Is  there 
any  danger  to  the  mother  or  child."  If  he  finds  the  head  presenting 
in  a  favorable  position  and  the  condition  otherwise  quite  normal 
he  may  answer  with  confidence,  that  there  is  no  sign  of  danger  to 
either  the  mother  or  child.  The  answer  should  always  be  as  favor- 
able as  possible.  The  physician  may  sometimes  be  in  doubt  or 
find  something  absolutely  unfavorable.  It  is  better  to  explain 
his  misgivings  to  the  relatives  of  the  patient  rather  than  to  the 
patient  herself. 

Another  question  very  commonly  asked  is :  "  How  long  will 
labor  last?  "  or  "When  will  it  be  over?  "  The  physician  should  be 
very  careful  as  to  how  he  answers  this,  because,  as  a  matter  of 
fact,  he  does  not  know,  nor  will  any  number  of  years  of  experience 
enable  him  to  give  a  definite  answer  to  such  a  question.  It  is  not 
necessary  to  say  in  an  abrupt  way,  "  I  do  not  know."  It  may  be 
well  to  say  that  if  everything  goes  on  well  it  is  likely  that  labor 
will  be  completed  within  a  few  hours  or  possibly  within  one  hour 
or  less,  but  the  little  clause  commencing  with  "  if  "  should  never 
be  forgotten. 

Diet  During  Labor. — It  is  not  necessary  to  give  any  very 
definite  rules  as  to  diet  during  labor.  In  a  large  proportion  of 
cases  the  patient  wants  but  little  and  may  generally  have  what 
she  desires.  Simple,  light  diet,  however,  is  best  for  her,  because 
the  process  of  labor  interferes  to  some  extent  with  that  of  diges- 


FIRST    STAGE    OF    LABOR  101 

tion.  In  considering  the  evil  offocts  of  overfeeding  during  labor 
it  is  always  well  to  have  in  view  the  atlministration  of  chloroform. 

Occasional  Absence  from  the  Room, — The  pressure  upon  the 
bladder  and  rectum  generally  causes  frequent  desire  to  pass  water 
and  evacuate  the  bowels.  On  this  account  the  physician  should 
make  it  a  point  to  retire  occasionally  into  another  room.  In  fact, 
if  he  has  a  good  nurse  it  is  better  for  him  to  be  out  of  the  room 
as  much  as  possible  during  the  early  part  of  the  first  stage.  It 
sometimes  happens  in  practise  among  the  poorer  classes  that  there 
is  no  second  room  to  which  one  can  retire.  In  such  a  case  there  is 
no  necessity  for  worry,  as  the  patient  will  be  forced  to  adapt  her- 
self to  the  circumstances  in  which  she  is  placed. 

Position  During  the  First  Stage. — The  patient  should,  as  a  rule, 
do  pretty  much  as  she  pleases  during  the  first  stage.  It  is  not 
necessary  nor  desirable  to  keep  her  in  bed  during  the  early  hours 
of  the  first  stage.  It  often  happens  that  the  pains  are  more  effec- 
tual when  she  is  sitting,  standing,  or  walking.  For  these  reasons 
the  question  of  position  may  be  left  to  the  patient.  If  the  pains 
become  feeble  when  she  lies  down  on  a  lounge  or  a  bed  one  may 
encourage  her  to  get  up  occasionally  and  walk  about.  It  is 
not  well,  however,  to  make  her  take  too  much  exercise  during  a 
tedious  labor. 

While  it  is  well  to  allow  a  woman  to  assume  any  position  she 
pleases  early  in  labor,  it  is  advisable  to  adopt  the  rule  that  a  woman 
shall  always  go  to  bed  when  the  pains  have  become  very  strong. 

Progress. — One  can  generally  have  a  fair  idea  of  the  progress 
of  labor  by  carefully  observing  various  symptoms.  As  labor  ad- 
vances the  pains  should  become  more  frequent,  stronger,  and 
longer  in  duration.  It  is  difficult  to  have  any  definite  idea  with- 
out occasional  vaginal  examinations.  These  should,  however,  be 
infrequent,  chiefly  because  we  wish  to  avoid  all  possible  chances 
of  causing  septicsemia.  When  the  os  uteri  and  soft  parts  below  it 
are  becoming  dilatable  and  dilated  labor  is  advancing. 

While  we  attach  much  importance  to  dilatation  of  the  os,  we 
should  attach  similar  importance  to  the  dilatation  of  other  parts 
which  must  occur  before  the  child  can  be  safely  born.  We  find 
the  following  conditions  in  practise:  Early  in  the  first  stage,  on 
making  a  vaginal  examination,  one  can  barely  insert  one  or  two 
fingers  sufficiently  far  to  reach  the  os  uteri.  The  perinseum,  pel- 
vic floor,  vulva,  vagina,  are  aU  more  or  less  rigid  and  contracted. 


102      MANAGEMENT  OF  NORMAL  LABOE 

After  labor  has  gone  on  satisfactorily  for  a  number  of  hours  a 
great  change  has  taken  place.  These  parts  have  become  first 
oedematous,  then  softened,  then  dilatable,  then  actually  dilated  or 
stretched.  One  may  now  introduce  within  the  vagina  the  whole 
hand  without  causing  any  more  pain  or  discomfort  than  was  pre- 
viously produced  by  the  introduction  of  one  or  two  fingers.  When 
all  these  structures  have  become  softened  and  dilated,  the  parts 
are  properly  prepared  for  the  expulsion  of  the  child. 

When  may  a  Patient  be  Left  ? — The  doctor  is  not  required  dur- 
ing the  whole  or  even  a  large  part  of  the  first  stage  of  labor.  He 
is  generally  summoned  during  that  stage,  makes  his  examination 
and  probably  reaches  certain  conclusions.  If  he  finds  that  very 
little  progress  has  been  made,  that  the  first  stage  is  likely  to  con- 
tinue for  many  hours,  he  may  leave  the  house,  pay  other  visits, 
and  return  at  a  certain  time.  When  is  it  safe  for  a  doctor  to  leave 
his  patient,  and  how  long  may  he  stay  away?  In  a  large  propor- 
tion of  cases  there  is  no  special  difficulty  in  deciding  early  in  labor 
that  he  is  not  likely  to  be  wanted  for  some  hours. 

In  the  following  case  a  doctor  of  my  acquaintance  was  absurdly 
cautious,  if  not  extremely  ignorant.  During  his  first  year  in  prac- 
tise he  was  called  to  see  a  patient  supposed  to  be  in  labor.  Three 
or  four  of  the  wise  women  of  the  neighborhood  surrounded  her 
bed.  The  patient  was  pulling  hard  on  a  sheet  attached  to  the 
lower  end  of  the  bed  and  was  encouraged  in  her  efforts  by  her  good 
friends  who  told  her  to  "hold  her  breath  and  bear  down."  The 
doctor  thought  things  looked  serious,  but  on  making  vaginal  exam- 
ination could  discover  little  or  nothing.  He  thought  this  was  due 
to  want  of  skill,  and  was  correct  in  so  thinking.  He  deemed  it 
safer,  however,  to  stay  a  portion  of  the  night.  After  some  three 
or  four  hours  the  pains  diminished  to  such  an  extent  that  the 
patient  fell  asleep.  He  then  thought  he  could  with  safety  leave 
the  house  and  told  the  friends  to  summon  him  when  he  was  re- 
quired. After  ten  weeks  he  was  again  summoned  to  the  house 
when  he  found  the  patient  actually  in  labor,  and  then  conducted 
the  case  in  a  way  that  was  satisfactory  both  to  the  friends  and 
himself. 

One  may  be  guided  largely  by  the  advice  of  Swain  and  Gooch, 
which  was  pretty  much  as  follows : 

The  physician  may  leave  the  patient  in  the  first  stage  of  labor 
under  the  following  circumstances  (Swain) : 


FIRST    STAGE    OF    LABOR  103 

1.  In  the  case  of  a  priniipara  if  tlie  presentation  is  natural  and 
the  OS  uteri  not  yet  dilated  to  the  size  of  a  fifty-cent  piece. 

2.  In  the  case  of  a  multipara  if  pains  are  few  and  weak,  the 
presentation  natural,  and  the  os  uteri  not  yet  dilated  to  the  size  of 
a  twenty-five  cent  piece. 

3.  In  any  case  if  there  have  been  very  few  pains  before  the 
physician's  arrival,  and  none  for  at  least  one  hour  afterward.  If 
the  pains  have  ceased  in  consequence  of  the  patient's  nervousness 
at  his  sudden  appearance  he  will,  by  waiting  an  hour,  have  allowed 
ample  time  for  the  effects  of  this  feeling  to  wear  off. 

Gooch  gave  excellent  advice  pretty  much  as  follows : 
The  propriety  of  leaving  a  patient  in  labor  will  depend  upon 
many  circumstances,  but  principally  upon  whether  or  not  it  is 
a  first  labor.  If  a  first  labor  and  one  can  be  within  call,  he  may 
visit  other  patients,  return,  ascertain  the  condition,  and  perhaps  go 
out  again.  This  he  may  do  until  the  os  uteri  is  dilated  to  the  size 
of  a  fifty-cent  piece,  a  process  which  will  occupy  about  two-thirds 
of  the  time  of  labor.  Afterward  no  prudent  man  should  leave  his 
patient  until  labor  is  completed.  But,  if  it  is  not  a  first  labor,  the 
progress  is  very  different.  The  patient  has  slow  pains  occurring 
about  every  ten  or  fifteen  minutes,  just  sufficient  to  remind  her  that 
she  is  in  labor.  The  accoucheur  is  informed  so  that  he  may  be 
easily  reached.  On  being  sent  for  after  a  notice  of  this  kind,  he 
will  find  that  these  trifling  pains  have  been  sufficient  perhaps  to 
completely  dilate  the  os  uteri,  ''the  pains  now  become  stronger  and 
the  membranes  more  distended — presently  they  are  ruptured — 
gush  goes  the  liquor  amnii,  and  if  his  arrival  has  not  been  pretty 
expeditious  he  may  be  greeted,  on  entering  the  room,  with  the 
squall  of  the  child  under  the  bedclothes.  If  I  am  called  to  a  labor 
which  is  not  the  first  and  find  the  pains  regular,  though  slight,  how- 
ever trifling  may  be  the  dilatation  of  the  os  uteri,  I  am  exceedingly 
shy  of  leaving  my  patient." 

Assistance,  Bearing-Down,  etc. — It  unfortunately  happens  that 
we  are  not  able  to  render  much  assistance  during  the  first  stage  of 
labor  even  though  the  woman  may  suffer  seriously  from  the  pecul- 
iar "grinding  "  pains.  It  may  be  laid  down  as  a  rule  that  one  can 
do  very  little  before  the  end  of  the  first  stage  in  a  normal  case. 
When  this  stage  continues  longer  than  it  should,  it  becomes  to  some 
extent  abnormal  and  tedious  and  may  require  definite  treatment. 
It  sometimes  happens  that  one  or  two  warm  baths  help  to  alleviate 


104      MANAGEMENT  OF  NORMAL  LABOR 

the  pains.  These  are,  of  course,  always  safe.  The  nurse  and  doc- 
tor should  do  all  that  they  can  to  encourage  the  patient.  While  it 
is  not  easy  to  tell  definitely  how  the  patient  may  be  assisted,  it  is 
less  difficult  to  tell  what  should  not  be  done.  The  patient  should 
not  be  allowed  to  tire  herself  out  by  pulling  on  a  sheet  and  by  the 
so-called  bearing-down.  It  is  well  to  guard  continuously  against 
anything  of  this  sort,  because  nurses  and  friends  of  the  patients  are 
so  apt  to  give  bad  advice  in  this  regard.  There  may  be  and  is  fre- 
quently a  time  for  ''holding  the  breath  and  bearing-down,"  as 
hereafter  mentioned,  but  that  is  not  during  the  first  stage. 

Preparation  of  Patient  Toward  the  End  of  the  First  Stage. — 
During  the  early  part  of  the  first  stage  the  patient  should  be  lightly 
clad  with  undergarments  covered  with  an  ordinary  wrapper. 
When  the  pains  become  strong  toward  the  end  of  this  stage  and  the 
patient  has  to  lie  on  her  bed,  which  has  been  prepared  in  accord- 
ance with  directions  already  given,  she  should  wear  her  night-dress 
and  a  pair  of  long  stockings,  or  the  Snively  combined  drawers  and 
stockings.  The  night-dress  should  be  pulled  up  under  the  arms 
and  properly  fastened  there  to  prevent  its  being  soiled  by  the  dis- 
charges ;  at  the  same  time  a  sheet,  folded  once,  should  be  neatly 
pinned  around  the  patient's  waist.  This  should  be  arranged  in 
such  a  way  that  it  can  be  easily  removed  along  with  the  Kelly  pad 
or  ordinary  obstetrical  pad  after  the  completion  of  labor.  Then 
the  patient  should  be  covered  with  an  ordinary  sheet  and  as  many 
bedclothes  as  are  required. 

Presence  of  Husband. — It  occasionally  happens  that  a  husband 
desires  to  be  present  during  labor,  although  why  he  should  do  so 
I  could  never  understand.  My  custom  is  generally  to  allow  him  to 
be  present  if  he  wishes  during  the  first  stage,  although  I  much  pre- 
fer his  absence.  He  can  do  no  good  and  is  apt  to  be  intensely 
alarmed  on  account  of  his  wife's  sufferings.  Under  such  circum- 
stances he  becomes  sometimes  almost  an  intolerable  nuisance,  and 
it  will  keep  one  pretty  busy  assuring  him  that  this  is  not  the  first 
time  in  the  history  of  the  world  that  a  woman  has  suffered  so 
severely.  During  the  progress  of  the  second  stage  I  generally  say, 
quietly,  "  You  had  better  leave  the  room  now,  we  are  getting  near 
the  end,"  without  giving  any  reasons  why.  He  almost  invari- 
ably leaves  when  so  instructed  without  making  any  trouble.  If  by 
any  chance  he  should  insist  upon  remaining,  I  have  nothing  more 
to  say. 


MANAGEMENT    OF    THE    SECOXD    STAGE        105 

Rupture  of  Membranes, — Rupture  of  ilic  membranes  may  occur 
at  any  time  during  the  labor  or  before  labor  has  commenced,  but 
under  ordinary  circumstances  should  take  place  about  the  end  of 
the  first  stage  or  at  the  commencement  of  the  second  stage.  Very 
often  such  rupture  may  be  said  to  be  the  dividing  line  between  the 
first  and  second  stages.  In  a  large  proportion  of  normal  cases  the 
history  is  somewhat  as  follows :  labor  advances  steadily  until  the 
child  is  in  proper  position  for  expulsion  and  the  mother's  soft  parts 
are  sufficiently  softened  and  dilated  to  allow  the  passage  of  the 
child,  the  membranes  suddenly  rupture,  pains  become  more  fre- 
quent and  more  vigorous  and  the  child  is  soon  expelled.  Some- 
times it  happens  that  such  rupture  does  not  take  place  without 
artificial  interference.  Under  such  circumstances  the  doctor  may 
cause  the  rupture  by  pressing  with  the  finger  end.  Years  ago  he 
was  advised  to  do  so  with  his  finger-nail,  sometimes  sharpened 
specially  for  the  purpose.  As  we  now  prefer  to  have  short  finger- 
nails we  must  use  the  finger-tip  or  some  hard  instrument.  An  or- 
dinary surgical  probe  answers  well.  If  no  probe  is  procurable  a 
coarse  hairpin  may  be  used ;  first  straighten  it  and  then  hold  it  for 
a  long  time  in  a  flame ;  after  it  is  thus  steriUzed  it  should  be  passed 
along  the  finger-tip  as  a  guide  and  pressed  against  the  bag  of  mem- 
branes during  a  pain.  In  rupturing  the  membranes  in  this  way  it 
is  well  to  hold  a  soft  bichloride  towel  closely  against  the  vulva  to 
receive  the  gush  of  waters  and  prevent  soiling  the  bed. 

MANAGEMENT  OF  THE  SECOND  STAGE 

During  the  first  stage  the  patient  has  been  allowed,  during  the 
greater  part  of  it  at  least,  to  sit,  stand  or  walk  pretty  much  as  she 
pleased;  in  the  second  stage  she  should  not  be  allowed  any  such 
liberties.  She  should  not  be  allowed  to  leave  her  bed  even  for 
evacuation  of  the  bladder  or  the  bowels,  because  of  the  danger  then 
existing  of  sudden  expulsion  of  the  child. 

The  pains  in  the  second  stage  are  changed  in  character.  The 
ordinary  uterine  expulsive  efforts  are  assisted  by  certain  of  the 
voluntary  muscles.  The  patients  are  very  apt  during  these  pains 
to  brace  their  feet  and  pull  on  something  near  them,  frequently  on 
the  hands  of  some  bystander.  These  voluntary  efforts  assist  to 
some  extent  in  the  expulsion  of  the  child,  but  in  the  so-called  pre- 
cipitate labors  may  do  a  certain  amount  of  harm.     It  is  well,  as  a 


106     MANAGEMENT  OF  NOEMAL  LABOE 

rule,  to  make  an  effort  to  regulate  these  voluntary  efforts.  When 
it  is  desirable  to  hasten  labor  she  is  directed  to  press  her  feet  against 
something  and  at  the  same  time  pull  on  a  sheet  attached  to  the  foot 
of  the  bed.  She  is  told  to  hold  her  breath  and  make  full  use  of  the 
accessory  powers  during  each  uterine  contraction.  When,  on  the 
other  hand,  the  uterine  contractions  are  already  too  strong,  she  is 
directed  to  cry  out  during  pains  instead  of  holding  her  breath. 

In  addition  to  the  ordinary  pains  accompanying  the  uterine 
contractions  the  patient  may  have  cramps  in  the  lower  limbs  which 
add  much  to  her  suffering.  Such  cramps  may  be  overcome  by 
powerfully  contracting  the  antagonistic  muscles.  For  example, 
in  case  of  cramps  in  the  calf  of  the  leg  the  patient  should  forcibly 
flex  the  foot  and  hold  it  so  until  the  muscular  spasm  subsides,  at 
the  same  time  the  cramped  muscle  should  be  well  rubbed  by  the 
doctor  or  nurse. 

Sometimes  the  ordinary  pains  are  extremely  acute  in  the  sacral 
region.  These  may  be  relieved  to  some  extent  by  firm  pressure  of 
the  palms  of  the  hands  against  the  sacrum  during  the  uterine  con- 
tractions. To  apply  such  pressure  is  generally  supposed  to  be  one 
of  the  duties  of  the  nurse,  and  is  sometimes  onerous  in  character 
in  a  prolonged  second  stage.  When  the  patient  finds  that  such 
pressure  furnishes  a  certain  amount  of  relief  she  will  insist  upon 
having  it  during  every  pain. 

It  not  infrequently  happens  that  an  abdominal  binder  firmly 
applied  may  slightly  relieve  these  pains.  Such  binder  may  also 
assist  expulsion,  especially  in  multiparas  with  pendulous  bellies. 

When  the  head  begins  to  distend  the  perinseum,  the  patient 
should  be  watched  with  great  care.  Some  recommend  that  at 
this  time  a  pillow  should  be  placed  between  the  knees  to  support 
the  thighs  or  that  somebody  should  lift  up  the  right  knee.  I  do 
nothing  of  this  sort  as  a  rule,  but  occasionally,  when  the  patient 
appears  to  feel  instinctively  that  expulsion  may  take  place  more 
readily  with  the  thighs  separated,  I  use  the  pillow  or  the  hands 
of  an  assistant  as  recommended. 

At  this  time  we  have  to  keep  several  things  in  view.  We  should 
watch  the  patient's  voluntary  efforts,  make  her  hold  her  breath 
when  necessary  and  bear  down,  or  ask  her  at  critical  moments  to 
cry  out  and  stop  bearing  down.  We  should  watch  the  perinseum 
and  vulva  as  they  are  being  distended.  We  should  keep  the  parts 
as  clean  as  possible. 


MANAGEMENT    OF    THE    SECOND    STAGE        107 

During  the  whole  of  the  second  stage  the  vulva  should  be  cov- 
ered with  a  diaper,  pad,  or  towel  which  has  been  soaked  in  an  anti- 
septic solution,  preferably  a  lysol  or  bichloride  solution.  Before 
each  examination  the  vulva  should  be  again  washed,  and  after  an 


Fig.  64. — Bladder  Empty  before  Labor. 

examination  a  fresh  pad  if  possible,  or  at  least  a  pad  freshly 
soaked  in  the  antiseptic,  should  be  reappHed. 

In  spite  of  all  precautions  the  descending  head  may  press  some 
faeces  from  the  rectum.  These  should  be  carefully  wiped  away 
with  a  piece  of  cotton  or  a  pledget  of  wool  soaked  in  the  lysol  solu- 
tion. In  using  any  such  pledget  be  careful  to  pass  it  from  before 
backward  so  as  to  wipe  from  and  not  toward  the  vulva.  Each 
pledget,  after  being  used,  should  be  thrown  into  the  slop-pail  or 
basin. 

Hot  fomentations  or  oily  preparations  have  sometimes  been 
used  to  help  relaxation  of  a  perinaeum  when  very  rigid.  I  am  very 
doubtful,  however,  as  to  the  efficacy  of  any  such  applications. 

Before  making  any  special  reference  to  the  management  of 
the  perinaeum  and  pelvic  floor  it  should  be  noted  that  this  is  a  very 


Fig.  65. — Bladder  Full  during  or  before  Labor. 

critical  time  in  the  process  of  labor.  One  should  be  keenly  on  the 
alert  to  do  all  in  his  power  to  assist  his  patient  without  doing  her 
any  harm.  There  is  no  time  in  our  professional  career  when  it  is 
more  important  for  us  to  be  what  the  world  calls  "calm,  cool  and 
collected."  A  careful  study  of  all  the  steps  in  this  stage,  all  the 
details  in  management  and  nursing,  and  all  the  precautions  to  be 


108 


MANAGEMENT  OF  NOEMAL  LABOR 


taken  from  an  aseptic  or  antiseptic  standpoint  should  give  us  a 
knowledge  which  will  enable  us  to  conduct  properly  any  normal 
case  without  serious  difficulty. 

Management  of  the  Perinaeum. — Many  procedures  which  have 
been  recommended  by  various  so-called  authorities  instead  of 
effecting  any  good  do  a  positive  injury.  One  of  the  most  harm- 
ful of  such  procedures  is  what  is  called  "supporting  the  peri- 
naeum." I  believe  it  is  a  great  deal  easier  to  do  too  much  than  too 
little  at  this  time. 


Fig.  66. — Controlling  Passage  of  Head  through  Vulva,  One  Hand  passed 

BETWEEN   THE    ThIGHS. 


It  was  stated  in  connection  with  the  mechanism  of  labor  that 
after  the  head  passes  downward  and  backward  in  the  pelvic 
cavity  for  a  certain  distance  it  turns  rather  sharply  forward  and 
continues  in  this  new  direction  until  it  emerges  from  the  vulva. 
During  this  part  of  its  descent  it  presses  against  the  floor  of  the 
pelvis  and  the  perinaeum  and  may  do  more  or  less  injury  to  these 
structures.  Such  injuries  are  more  likely  to  occur  in  first  labors. 
It  is  estimated  by  some  that  lacerations  of  the  pelvic  floor  and 
perinaeum  occur  in  40  per  cent,  of  first  and  15  per  cent,  of  subse- 


MAN"AGEME?TT    OF    THE    SECOND    STAGE 


109 


quent  labors.  Such  injuries  have  frequently  very  serious  effects. 
A  strong,  healthy  young  woman  may  give  birth  to  a  healthy  child 
and  may  make  a  fairly  good  recovery.  She  and  her  friends  are 
perfectly  satisfied  with  her  condition  for  a  time  after  labor,  but 
even  under  such  apparently  favorable  circumstances  the  pelvic 
floor  may  be  so  severely  injured  as  to  cripple  her  for  the  rest  of  her 
life.  It  is  probable  that  at  least  half  of  such  injuries  might  be 
avoided  by  careful  and  judicious  methods  of  management.  Many 
lacerations  of  the  pelvic  floor,  which  ought  to  be  readily  apparent 
to  any  one  who  looks  for  them,  are  not  recognized  because  they 
are  not  properly  looked  for.  In  first  labors  the  fourchette  is  gen- 
erally torn,  a  slight  rupture  of  the  peringeum  is  also  c[uite  common 
and  is  generally  observed.     A  complete  rupture  of  the  perineum 


Fig.  67. 


-C'oxiKuLLixu  Passage  of  Head  through  Vulva,  Both  Hands 
BEHIND  Thighs. 


passing   through   to  the    rectum    occasionally    occurs,  and  is,  of 
course,  generally  observed,  but  in  a  large  proportion  of  cases  seri- 
ous injuries  take  place  in  the  pelvic  floor  which  are  not  recognized. 
A  certain  amount  of  time  must  elapse  before  the  pelvic  floor 


110 


MAI^AGEMEXT    OF    NORMAL    LABOR 


and  perinseum  are  in  a  condition  to  allow  the  child  to  pass  with 
safety.  After  the  uterine  contractions  have  continued  for  a  cer- 
tain time  the  pelvic  floor  begins  to  bulge.     It  may  look  to  a  begin- 


FiG.  68. — The  Pelvic  Floor  seen  from  Above   (Kelly). 

ner  at  this  time  as  if  labor  ought  to  be  concluded  very  quickly. 
It  is  undesirable,  however,  to  have  the  head  expelled  for  at  least 
half  an  hour  after  such  bulging  commences  in  primiparse,  and 
probably  about  twenty  minutes  in  multiparae. 

Position  of  the  Patient. — The  patient  may  lie  either  on  her  side 
or  on  her  back  during  the  first  and  part  of  the  second  stage.  As 
soon  as  the  head  is  found  to  distend  the  pelvic  floor  and  perinseum 
the  patient  should  be  placed  on  her  left  side,  with  her  buttocks 
near  the  edge  of  the  bed  and  her  thighs  and  legs  flexed.  The  pelvic 
floor  and  perinseum  are  now  in  plain  view  and  should  be  kept  so 


MANAGEMENT    OF    THE    SECOND    STAOE        111 

until  the  head  and  shoulders  are  expelled.  The  physician  stands 
at  the  side  of  the  bed  with  his  face  toward  the;  foot,  having  the 
right  hand  ready  to  use  pr(>ssure  from  behind  and  the  l(;ft  ready  to 
manipulate  the  vertex,  tiic  left  forearm  resting  on  her  right  or 
uppermost  thigh.  As  a  rule,  especially  when  the  thighs  are 
flexed,  both  hands  can  be  kept  posterior  to  the  thighs  and  buttocks ; 
but  when  the  patient  is  restless  or  the  thighs  are  extended  so  as  to 
be  in  a  line  with  the  body,  it  is  better  to  have  the  nurse  hold  up 
the  right  leg  and  pass  the  left  arm  over  the  mons  veneris  and 
between  the  thighs  to  the  vulva.     This  position  is  sometimes  awk- 


FiG.  69. — The  Pelvic  Floor  seen  from  Below  (Kelly). 


ward,  but  it  affords  a  good  opportunity  to  completely  control  the 
patient.  In  doing  this  the  hand  should  be  wrapped  in  an  anti- 
septic or  aseptic  towel  while  it  is  passing  over  the  mons  veneris 
to  prevent  it  from  becoming  infected. 

The  bladder  should  be  empty  at  this  time,  because  fulness  of 
this  organ  may  considerably  prolong  the  second  stage.  During  the 
strong  pains  of  this  stage  chloroform  may  be  administered  to  the 
obstetrical  degree. 

When  the  head  presses  with  some  force,  as  shown  by  the  bulging 
of  the  pelvic  floor  and  perinaeum,  an  effort  is  made  to  prevent  lacer- 
9 


112 


MANAGEMENT  OP  NOEMAL  LABOE 


ation  in  the  following  way.  The  accoucheur  puts  a  clean  towel  over 
the  anus  and  presses  with  the  heel  of  the  right  hand  between  the 
anus  and  the  tip  of  the  coccyx  in  such  a  way  as  to  push  the  head 
forward  toward  the  symphysis  pubis;  and  places  the  thumb  and 
fingers  of  the  left  hand  over  the  vertex,  seizing  the  latter  if  he  can. 

One  thus  gets  good  control  over  the  head.  It  is  very  much  as  if 
a  person  had  one  hand  over  the  vertex  and  the  other  over  the  chin 
and  mouth  without  the  intervention  of  the  perinseum  and  pelvic 
floor.     One  gets  still  better  control  over  the  head  as  it  is  passing 

Urethra     Clitoris 


Vagina  y\    \ 


M.  Constrictor  cunni 
M.   Ischio-cavernosus 


M.  transversus  perinei 

Levator  ani 


Centrum  tendineum 


Sphincter  ani 


Fig.   70. — Pelvic  Floor  distended  by  presenting  Part,  showing  Superficial 
Muscles  of  Perineum  (Bumm). 


through  the  vulva  by  seizing  it  with  the  left  hand  over  the  occiput 
and  the  right  hand  over  the  forehead  in  front  of  the  fourchette.  In 
this  way  one  can  prevent  undue  extension  and  too  rapid  advance 
of  the  head,  while  he  keeps  part  of  the  heavy  strain  off  the  pelvic 
floor  and  the  perinseum. 

If,  at  this  time,  the  perinseum  seems  in  danger,  as  shown  by 
undue  tightening  of  the  skin  around  the  vulva,  the  patient  is 
directed  to  extend  the  legs  and  thighs  so  as  to  bring  them  in  a 
straight  line  with  the  body,  such  procedure  having  a  tendency  to 
considerably  slacken  the  tension  around  the  vulva.  A  backward 
arching  of  the  patient's  back  also  assists  in  relieving  such  tension. 


MANAGEMENT    OF    THE    SECOND    STAGE        113 

When  the  pelvic  floor,  perinaeum,  and  vulva  seem  sufficiently 
softened  and  dilated,  and  the  head  sufficiently  far  advanced,  one 
may  hold  it  steadily  with  two  hands,  and  gently  slip  it  out  during 
an  interval  between  the  pains.  When  this  can  be  done  there  is 
sometimes  less  danger  of  laceration  than  when  the  head  is  expelled 
during  the  acme  of  the- muscular  contractions.  Some  prefer  to  put 
the  thumb  or  fingers  of  the  right  hand  in  the  rectum  instead  of 


Fig.  71. — Birth  of  Head,  Scalp  appearing  at  Vulva  (Williams). 


behind  the  anus.  This  method,  while  no  more  efficient  than  the 
other,  perhaps  not  so  much  so,  is  obviously  objectionable.  As 
soon  as  the  head  is  expelled  or  extracted  the  right  hand  is 
moved  forward  to  support  it  and  the  left  is  placed  over  the 
fundus  uteri. 

Emergence  of  the  Head  and  Neck. — When  the  head  is  born  the 
neck  is  examined  to  see  if  there  is  a  loop  of  cord  around  it.  When 
one  or  more  are  found  the  loop  or  loops  are  slipped  over  the  head. 


114 


MANAGEMENT  OF  NOEMAL  LABOE 


If  the  cord  is  too  tight  to  allow  this  the  loop  is  passed  over  the 
shoulders  as  they  emerge.  If  neither  one  of  these  can  be  done  the 
cord  is  cut  with  a  pair  of  scissors,  and  a  clip  is  put  on  each  divided 
end,  or,  if  there  are  no  clips  at  hand,  the  proximal  end,  which  is 


Fig.   72. — Birth  of  Head,   Vulva  partially  distended   (Williams). 


recognized  by  the  spouting  of  two  umbilical  arteries,  is  held  between 
the  thumb  and  index  finger  until  it  can  be  tied.  While  the  physi- 
cian is  thus  manipulating  the  cord  the  nurse  should  press  with  some 
force  (not  too  much)  over  the  fundus  uteri. 

The  child's  face,  after  expulsion  of  the  head,  is  at  first  white  or 
somewhat  pale,  but  soon  becomes  purple.  This  may  cause  alarm 
in  the  beginner,  but  it  generally  involves  no  special  danger  to  the 
child.  The  head  is  now  the  only  part  of  the  foetal  body  free  from 
pressure  and,  consequently,  the  blood  rushes  into  it  and  is  pre- 
vented from  returning  freely  to  the  body  by  the  pressure  about  the 
neck.     There  is  danger,  however,  sometimes.     If  the  child's  face 


MANAGEMENT    OF    TTIE    SECOND    STAGE        115 

remains  purple  during  the  interval  between  the  pains  there  is  cer- 
tainly danger  of  asphyxiation.  If  a  ligature  has  l^een  put  on  the 
cord  there  is  also  danger  of  asphyxiation.  When  such  danger 
exists  one  should  extract  quickly.  If  there  is  no  prolonged  con- 
gestion of  the  child's  face,  and  no  cord  complication,  one  should 
generally  wait  until  the  child  is  expelled  by  Nature's  efforts. 

The  inexperienced  physician  or  midwife  is  apt  to  get  flurried  at 
this  time  and  make  injudicious  efforts  to  extract  the  child.  Rapid 
extraction  of  the  shoulders,  under  such  circumstances,  frequently 
causes  serious  lacerations,  and  sometimes  inflicts  serious  injuries  to 
the  child's  spine.     It  is  quite  right  for  the  physician  to  assist  ex- 


FiG.   73. — Birth  of  Head,  Vulva  completely  distended  (Williams). 


pulsion  by  rubbing  or  kneading  the  uterus  or  by  pressure  with  the 
hand  over  the  fundus.  Generally  with  such  slight  assistance  the 
shoulders  descend,  rotate,  and  emerge  quickly.  After  the  expul- 
sion of  the  shoulders  the  remaining  portion  of  the  body  follows 


116 


MANAGEMENT  OF  NORMAL  LABOR 


rapidly.  As  soon  as  the  shoulders  are  expelled  the  patient  should 
be  turned  on  her  back. 

Quick  Extraction  of  Shoulders. — When  interference  becomes 
necessary  for  the  extraction  of  the  shoulders  one  of  two  methods 
may  be  employed. 

1.  Hook  the  finger  in  the  posterior  axilla  from  behind  and  lift 
the  shoulder  over  the  edge  of  the  perinseum,  while  the  anterior 


Fig.   74. — Birth  of  Head,   showing  Delivery  by  Extension   (Williams). 


shoulder  still  rests  behind  the  symphysis.  Gently  extract  the  pos- 
terior arm.  The  anterior  shoulder  will  now  pass  easily  under  the 
pubic  arch.  At  the  same  time  the  assistant  should  press  over  the 
fundus. 

2.  Push  the  neck  backward  against  the  perinaeum  and  pull 
slightly  so  as  to  bring  down  the  anterior  shoulder;  then  push  the 
neck  forward,  pass  the  finger  under  the  posterior  axilla  and  extract. 

There  is  generally  or  always  danger  of  asphyxiation  when  two 
pains  have  occurred  after  the  expulsion  of  the  head. 


MANAGEMENT    OF    THE    SECOND    STAGE        117 

Sometimes  the  ovum  is  exj^clkHl  intact — that  is,  with  the  child 
completely  enveloped  in  the  membranes.  In  such  cases  the  mem- 
branes should  be  ruptured  at  once  to  prevent  the  child  from  being 
smothered.  The  membranes  over  the  head,  under  such  circum- 
stances, are  known  as  the  "caul."  In  former  days  a  caul  used  to 
be  considered  very  lucky,  and  was  not  uncommonly  sold  for  a  large 
sum  of  money.  I  think  the  expulsion  of  an  intact  ovum  is  more 
common  in  twin  lal^ors,  the  first  child  being  delivered  after  rupture 
of  the  membranes  in  the  ordinary  way,  and  the  second  being  de- 
livered surrounded  by  its  unruptured  membranes. 

Tying  the  Cord. — In  former  days,  when  it  was  the  fashion  to 
keep  the  patient  on  her  side  until  after  the  expulsion  of  the  placenta 


Fig.  75. — Birth  of  Head,  Face  falling  backward  toward  Anus  (Williams). 


the  child  was  simply  placed  on  the  bed,  below  or  behind  the  pa- 
tient's buttocks,  and  remained  there  until  after  the  ligaturing  and 
division  of  the  cord.  If,  however,  the  patient  is  placed  on  her 
back,  as  I  strongly  recommend,  before  the  complete  expulsion  of 


118 


MANAGEMENT  OF  NOEMAL  LABOE 


the  child,  it  is  not  quite  so  convenient  to  care  for  the  latter.  If  the 
cord  is  fairly  long  the  mother  may  flex  the  right  thigh  and  leg  while 
the  child  remains  mider  the  right  knee  or  close  to  the  outer  side  of 
the  thigh;  or,  the  patient  may  separate  the  thighs  and  the  child 
be  left  between  the  knees.  The  position  of  the  mother  on  her  back 
after  the  completion  of  the  second  stage  involves  a  certain  amount 
of  exposure,  but  this  is  a  small  matter  when  compared  with  the 


Fig.   76. — Birth  of  Head,   External  Rotation   (Williams). 

benefits  to  be  derived.  While  waiting  to  ligature  the  cord  still 
keep  the  left  hand  on  the  fundus  uteri.  I  repeat  this  direction 
somewhat  frequently  on  account  of  its  importance;  at  the  same 
time  I  wish  again  to  insist  upon  it  that  there  should  not  be  any 
rough  kneading  or  strong  pressure  used. 

It  is  now  generally  recognized  that  we  should  wait  for  some 
time  after  the  birth  of  the  child  before  tying  the  cord.  During 
this  time  the  foetal  circulation  is  well  aspirated,  especially  after  the 
child  has  cried.     It  is  probable  that  during  this  process  of  aspira- 


MANAGEMENT    OF    THE    SECOND    STAGE        119 


tion  the  chikl  gains  two  or  throe 
ounces  of  blood.  It  is  thought  by 
some  that  the  diminution  in  the 
size  of  the  placenta  through  the 
abstraction  of  this  blood  is  one  ol 
the  causes  of  the  separation  of 
the  placenta  from  the  uterine  wall. 
Some  say  that  we  should  wait  until 
the  cord  ceases  to  pulsate.  I  do 
not  know  how  long  this  might 
take  in  certain  instances,  but  I 
make  it  a  practise  not  to  wait  any 
longer  than  five  minutes,  especially 
if  the  child  has  cried.  The  physi- 
cian should  see  that  there  is  no 
protrusion  of  the  bowel  in  the  cord. 
When  the  cord  is  thick  one 
may  squeeze  some  of  the  gelatinous  matter  toward  the  placenta. 
This  is  called  stripping  the  cord  and  is  to  some  extent  dangerous 


Fig.  77. — Soudan  Labor  Chair. 
(Photograph  by  James  F.  W.  Ross.) 


Fig.  78. — Demonstration  of  the    Method  of  conducting  Labor  in  Soudan, 

Africa. 

Patient  in  labor  chair  in  the  grounds  of  the  Civil  Hospital  in  Obdurman,  opposite 
Khartoum.  Hospital  behind  with  part  of  the  surrounding  wall  visible  on  the 
right.  Woman  behind  "helping"  patient.  Native  midwife  "waiting." 
(From  photograph  taken  by  Dr.  James  F.  W.  Ross,  with  the  permission  of 
Dr.  Christopherson,  Superintendent,  February,  1904. 


120 


MANAGEMENT  OF  NOEMAL  LABOE 


because  it  is  liable  to  do  violence  to  the  navel.  The  safer  plan  is  to 
simply  squeeze  the  cord  at  the  spot  where  the  ligature  is  applied. 
After  the  cord  has  been  tied  and  cut,  the  nurse  may  take  the 
babe,  or  it  is  sometimes  more  convenient  for  the  physician  to  do  so, 
and  hand  it  to  the  nurse.  This  should  not  be  done  in  a  clumsy  and 
awkward  manner.     A  child  covered  with  the  vernix  caseosa  is 


Fig.  79. — Native  Midwife  holding  out  heh  Hands  to  receive  the  Babe. 
(From  photograph  by  Dr.   Ross.) 


sometimes  rather  slippery  and  therefore  difficult  to  hold.  It  will 
not  inspire  confidence  on  the  part  of  the  onlookers  if  the  child  is 
allowed  to  fall  to  the  floor.  I  always  pick  up  the  child  in  a  definite 
way  as  described  by  Uzziel  Ogden.  Place  the  left  hand  under 
neck  and  shoulders  so  that  the  thumb  and  index  finger  support  the 
head,  and  let  the  thumb,  index,  and  middle  fingers  of  the  right 
hand  seize  the  thighs  immediately  above  the  knees,  the  index  finger 
being  between  them.     Or  the  hands  may  be  reversed. 


.  CHAPTER  VII 

NORMAL  LABOR   {Continued) 

THIRD  STAGE  OF  LABOR 

Crede's  Method. — About  fifty  years  ago  Crede  introduced  into 
Germany  a  certain  method  of  expressing  the  placenta  without  any 
suspicion  apparently  (according  to  Robert  Barnes)  that  the  same 
method  had  long  been  practised  in  Great  Britain.  It  was  prac- 
tised especially  in  Dublin  and  the  procedure  was  minutely  de- 
scribed by  McChntock  and  Hardy  in  1848.  About  the  time  that 
obstetricians  of  Great  Britain  w^ere  learning  the  dangers  of  rapid 
expulsion,  physicians  of  the  continent,  United  States,  and  Canada 
were,  as  a  general  rule,  practising  the  Crede  method.  The  impor- 
tant difference  between  methods  in  vogue  in  the  middle  of  the  last 
century  may  be  best  understood  by  the  use  of  two  words — ex- 
traction and  expression.  The  older  method  of  extraction  in  the 
course  of  years  gave  way  to  that  of  expression.  The  Rotunda 
school  of  Dublin  was  the  first  in  the  world  to  adopt  expulsion  or 
expression. 

In  a  few  years  many  of  the  disciples  of  Crede  on  the  continent, 
and  those  of  the  Rotunda  in  Great  Britain,  discovered  that  rapid 
expulsion  was  frequently  followed  by  evil  results.  One  of  the  first 
in  Canada,  and  perhaps  in  North  America,  to  recognize  the  evils 
of  rapid  expulsion  was  George  A.  Tye,  of  Chatham,  Ontario.  After 
carrying  out  for  some  years  the  original  Crede  method  he  relin- 
quished it  in  1887,  and  adopted  almost  in  its  entirety  the  expectant 
method.  There  was,  during  all  these  years  between  1850  and  1887, 
some  doubt  and  uncertainty  as  to  the  exact  nature  of  the  methods 
of  expression.  Fortunately  we  are  able  now  to  lay  down  definite 
rules  as  to  the  conduct  of  the  third  stage  of  labor  which  are  gen- 
erally considered  correct  by  obstetricians  in  all  countries. 

What  was  Creole's  method?  Some  confusion  has  arisen  as  to 
this  term  from  the  fact  that  Crede  himself,  after  some  years,  made 
an  important  change  in  his  method.     His  practise,  in  the  earlier 

121 


122 


NOEMAL   LABOR 


years  of  his  work  especially,  was  to  apply  friction  to  the  uterus  as 
soon  as  the  child  was  expelled.  When  the  first  uterine  contraction 
occurred  he  grasped  the  fundus  in  his  hand  with  the  thumb  on  the 
anterior  wall  and  the  four  fingers  on  the  posterior  wall  and  thus 
squeezed  out  the  placenta — ''as  the  seed  from  a  ripe  cherry  com- 
pressed between  the  thumb  and  fingers."  His  aim  was  to  com- 
plete the  operation  as  soon  as  possible,  and  according  to  some  of 
his  earlier  statistics  the  average  duration  of  the  expression  was 
four  and  one-half  minutes.  This  method  was  popular  for  years, 
although  many  opposed  it.  After  a  time  the  opposition  grew 
stronger  and  a  complete  reaction  set  in.  It  was  then  condemned 
as  harsh  and  unscientific.  The  adverse  criticisms,  which  became 
so  common  at  this  time,  were  essentially  correct.  In  the  hands  of 
many,  if  not  the  majority,  the  method  of  expression  was  extremely 
harsh  and  caused  much  unnecessary  pain.     Too  much  attention 

was  given  to  the  rapid  expulsion  of  the 
placenta  and  too  little  to  the  expulsion 
or  extraction  of  the  membranes;  as  a 
consequence  large  portions  of  the  latter 
were  frequently  left  in  the  uterus.  The 
rapid  expression  of  the  placenta  emp- 
tied the  uterus  before  retraction  and 
contraction  were  properly  established. 
Under  such  circumstances  accou- 
cheurs were  likely  to  meet  with  two 
conditions,  inertia  of  the  uterus  and 
retention  of  membranes,  which  together 
favored  post-partum  haemorrhage,  and 
yet  Crede's  chief  aim  was  to  prevent 
such  hsemorrhage. 

It  is  somewhat  remarkable  that  re- 
sults so  varied  should  follow  any  one 
plan  of  treatment.     It  is  probable  that 
in  the  hands  of  Crede  and  his  assistants 
the  results  were  fairly  satisfactory,  but  the  bad  results  were  very 
serious  in  the  practise  of  many  who  were  either  unskilled  or  im- 
properly taught. 

Crede  himself,  after  practising  his  methods  some  years,  recog- 
nized certain  defects  and  accepted  the  rule  that  no  one  should 
endeavor  to  squeeze  out  the  placenta  until  at  least  fifteen  minutes 


Fig.  80. — Placenta   in  Utb 
Rus  AFTER  Birth  of  Child. 


THIRD    STAGE    OF    LABOR 


123 


had  expired  after  the  expulsion  of  the  child.  This  extremely 
important  modification  of  Crede's  original  method  is  a  great 
improvement,  and  while  it  makes  the  plan  almost  perfect  in  the 
opinion  of  the  great  majority,  will  account  for  some  of  the  mis- 
conceptions which  have  appeared  in  the 
numerous  discussions  •  which  have  taken 
place  on  this  subject. 

Elements  in  the  Third  Stage. — We  have 
received  some  very  valuable  lessons  from 
Dohrn  and  Ahlfeld  in  Germany,  and  also 
from  the  Edinburgh  and  Dublin  schools  in 
Great  Britain.  We  now  know  that  there 
are  two  separate  and  distinct  elements  in 
the  third  stage  of  normal  labor. 

1.  The  spontaneous  separation  of  the 
placenta  and  membranes. 

2.  The  delivery  of  the  placenta  and 
membranes. 

The  Dublin  and  Crede  schools  taught  us 
that  the  old  method  of  removing  the  pla- 
centa by  pulling  on  the  cord  was  wrong. 
Careful  observers  during  the  last  twenty 
years  have  discovered  that  we  should  allow 
Nature  to  complete  the  separation  of  the 
placenta  and  membranes  without  any  of 
that  violent  rubbing  and  kneading  which 

used  to  be  done  immediately  after  the  expulsion  of  the  child. 
This  process  of  separation  is  generally  completed  in  from  fifteen 
to  thirty  minutes,  probably  in  the  majority  of  cases  in  less  than 
twenty  minutes.  As  soon  as  the  separation  takes  place  the  pla- 
centa is  pushed  by  the  ordinary  uterine  contractions  wholly  or 
partially  into  the  vagina,  and  in  a  certain  indefinite  time  thereafter 
is  generally  expelled  from  the  vulva.  I  think  it  was  Ahlfeld  who 
first  pointed  out  that  this  separation  and  expulsion  of  the  placenta 
into  the  canal  of  delivery  are  shown  by  the  advance  of  the  cord  and 
by  the  firm  continuous  contraction  and  retraction  of  the  uterus, 
which,  while  becoming  more  narrow,  generally  rises  somewhat 
higher  in  the  abdominal  cavity  and  at  the  same  time  becomes  more 
mobile.  This  apparent  lengthening  of  the  cord  is  clearly  shown 
if  one  follows  the  Rotunda  plan  of  putting  a  second  ligature  on  the 


Fig.  81. — Placenta  Sep- 
arated AND  PUSHED 
PARTIALLY  INTO  Va- 
GINA. 


124 


NORMAL    LABOR 


cord  close  to  the  vulva.  When  the  placenta  passes  wholly  or 
partially  into  the  vagina  this  vulvar  ligature  passes  about  two 
inches  downward. 

Although  violent  rubbing  and  kneading  of  the  uterus  imme- 
diately after  expulsion  of  the  child  is  harmful  we  should  not  go 
to  the  other  extreme  of  leaving  the  uterus  to  look  after  itself. 
One  should  keep  the  left  hand  on  the  uterus,  pressing  gently  or 
rubbing  gently  with  the  tip  of  the  finger  between  the  recti  mus- 
cles. If,  however,  serious  haemorrhage  should  occur  at  this  time 
we  shall  generally  find  feeble  contractions.  In  such  a  case  the 
uterus  should  be  grasped  firmly  so  as  to  induce  a  contraction  and 


Fig.  82. — Placenta  being  Expelled. 
Nurse  holding  plate  to  receive  it. 


arrest  the  haemorrhage.  As  soon  as  separation  and  slight  down- 
ward movement  of  the  placenta  have  occurred,  pressure  should 
be  made  over  the  fundus  in  the  way  described  by  Crede  or  with 
the  palmar  surface  of  the  two  hands,  the  fingers  interlocking  each 
other.  The  placenta  can  generally  be  pushed  out  during  the  first 
firm  contraction;  if  not,  pressure  should  be  continued  during 
each  subsequent  contraction.  Slight  traction  on  the  cord  in  con- 
junction with  pressure  on  fundus  is  sometimes  allowable  when 
the  placenta  is  partially  or  wholly  in  the  vagina.  Caution  is, 
however,  always  required.  If  pressure  during  three  or  four  con- 
tractions does  not  expel  the  placenta  there  is  probably  some  ab- 
normal condition. 


THIRD  STAGE  OF  LABOR  125 

Extraction  of  the  Membranes. — After  the  oxpnlsioti  of  the  pla- 
centa, we  have  to  consider  tin  extraction  of  the  membranes.  The 
term  extraction,  as  distinguished  from  expulsion,  is  used  advisedly. 
It  is  a  very  common  practise  to  continue  pressing  on  the  uterus 
and  at  once  commence  turning  the  placenta  so  as  to  twist  the  mem- 
branes into  a  cord.     I  believe  the  result  of  this  method  is  frequently 


Fig.  83. — Placental    Site    near    Fundus,  Rough    and    Prominent,  often 
Mistaken  for  Portion  of  Retained  Placenta.     (Tor.  Univ.  Museum.) 


to  tear  through  the  membranes  while  a  considerable  portion  of  the 
same  is  retained  in  the  uterus.  We  are  so  thoroughly  imbued 
with  the  vis  a  tergo  idea  in  connection  with  the  delivery  of  the  child 
and  placenta  that  we  are  apt  to  forget  that  the  extraction  of  the 
membranes  should  be  effected  by  an  entirely  different  process. 


126  KOEMAL    LABOR 

Plenty  of  time  should  be  taken  in  this  procedure,  not  less  than  five 
to  ten  minutes.  The  accoucheur  should  not  drag  away  the  mem- 
branes rapidly.    On  the  other  hand,  he  should  support  the  placenta 


Fig.  84. — Pregnant  Uterus  at  Seven  Months. 
Note  the  height  of  the  fundus  above  the  Fallopian  tubes. 

in  such  a  way  that  it  will  not  pull  forcibly  on  them.  He  should 
watch  for  slight  relaxation  or  dilatation  of  the  uterus  and  during 
such  coax  them  away.  If  one  detects  a  slight  tear  on  one  side  he 
should  pull  gently  on  the  other.  A  httle  judicious  twisting  may 
assist  sometimes,  but  one  should  remember  the  dangers  connected 
therewith  and  beware.  During  the  delivery  of  the  placenta  and 
the  extraction  of  the  membranes  the  nurse  should  hold  the  soup- 
plate  or  platter,  which  has  been  set  aside  for  this  purpose,  between 
the  thighs  pressed  against  the  perinseum  to  receive  the  placenta, 
the  gush  of  blood  which  generally  follows  it,  and  the  membranes. 
If  no  abnormal  condition  is  present  it  is  quite  unnecessary  to  in- 
troduce the  fingers  or  hand  into  the  vagina  or  uterus  during  the 
third  stage  of  labor.  The  objections  to  such  procedures  are  not 
based  on  mere  inutility,  but  on  the  fact  that  this  is  the  period  when 


THIED    STAGE    OF    LABOR 


127 


there  is  the  greatest  danger  of  introducing  septic  matter  into  the 
system.  The  passage  of  the  child  has  produced  tears  of  greater 
or  lesser  extent  in  the  cervix,  vagina,  and  perinseum,  or  perhaps  in 
all  three  combined,  and  the  open-mouthed  blood-vessels  and  lym- 
phatics are  ever  ready  to  absorb  and  distribute  through  the  body 
any  poison  which  comes  within  their  reach. 

Without  discussing  at  length  the  physiology  of  placental  separa- 
tion and  expulsion,  we  may  presume  that  the  detachment  of  the 
placenta  is  caused  by  contraction  in  the  area  of  its  insertion,  in 
which  contraction  the  placenta  itself  can  not  share.  Separation 
occurs  probably  in  different  ways,  varying  according  to  the  posi- 
tions of  the  placental  insertion.  When  inserted  at  the  fundus  it 
begins  to  separate  at  the  center,  forming  a  cavity  in  which  a  certain 


Fig.  85. — Pregnant  Uterus  with  Front  Wall  removed  showing  Section  of 
THE  Uterine  Wall,  Large  Surface  of  Placenta  with  Uterine  Surface 
of  Membranes  below  and  to  the  Left. 


amount  of  blood  accumulates.     When  separation  is  completed  the 

foetal  surface   of  the  placenta  falls  toward  the  cervical  canal  and 

the  membranes  follow,  being  turned  inside  out  and  containing  a 
10 


128 


NOEMAL    LABOE 


certain  amount  of  blood.  The  placenta  and  membranes  emerge 
in  the  same  order  from  the  vulva.  When  the  placenta  is  inserted 
in  the  anterior  or  posterior  wall  the  separation  begins  either  at  the 


Fig.  86. — Placenta  and  Membranes  turned  to  the  Left  showing   Section 
OP  Placenta,  Fcetal  Surface  of  the  Placenta,  Cord,  and  Fcetus. 


upper  or  lower  edge  and  as  it  descends  it  may  appear  at  the  vulva 
by  its  foetal  or  maternal  surface.  The  lower  the  insertion  the  more 
apt  is  the  maternal  surface  to  present  at  the  vulva.  These  views 
do  not  coincide  with  those  of  Matthews  Duncan  and  others,  who 
thought  that  when  there  was  no  interference  the  common  method 
of  separation  was  such  that  the  edge  of  the  placenta  presented  at 
the  cervix.  The  practical  point  to  bear  in  mind  in  this  connection 
is  that  when  traction  on  the  cord  is  employed  before  the  pla- 
centa is  dislodged  from  its  place  of  insertion  the  initial  separation 
is  central,  a  partial  vacuum  is  thereby  produced  which  sucks  the 
blood  from  the  larger  uterine  vessels  or  tends  to  invert  the  weak 
and  flaccid  uterine  walls.  This  generally  admitted  fact  furnishes 
the  strongest  and  most  convincing  argument  against  the  pernicious 
practise  of  early  traction  on  the  cord. 


THIRD    STx\GE    OF    LABOR 


129 


There  are  three  objects  gained   by   the  iiKKleru   or  modified 
Crede's  method. 

1.  By  maintaining  retraction  anrl  contraction  of  the  uterus  it 
prevents  hicmorrhage. 

2.  By  causing  comparatively  rapid  expulsion  it  tends  to  prevent 
the  dangers  arising  from  retention. 

3.  By  thoroughly  emptying  the  uterus  without  introducing  the 
fingers  into  the  genital  canal  it  tends  to  prevent  septicaemia. 

The  Membranes. — As  already  stated,  the  membranes  do  not,  as 
generally  supposed,  form  the  sheath  of  the  cord.     The  external 


Fig.  87. — A  Pregnant  Uterus  with  Po.sterior  Wall  removed  showing 
Section  of  the  Uterine  Wall  and  Fcetus  in  Position,  with  Cord  around 
Neck  .\nd  Thigh. 


layer  of  the  cord  is  really  the  skin  of  the  embryo,  as  pointed  out 
first,  I  think,  by  Minot.  On  examining  the  membranes  one  finds 
the  two  layers,  which  can  generally  be  easily  separated.     When  the 


130  NOEMAL   LABOR 

membranes  are  not  inverted,  that  is  when  they  are  right  side  out, 
the  chorion  is  the  external  or  outermost  layer  and  is  continuous 
with  the  edge  of  the  placenta.  The  amnion  is  internal  or  inner- 
most. One  may  strip  the  amnion  from  the  surface  of  the  placenta 
as  far  as  the  root  of  the  cord  and  no  further.  This  clinical  fact  has 
been  noticed  by  such  men  as  Galabin  and  others,  although  Berry 
Hart  speaks  of  it  as  if  it  has  been  entirely  overlooked  until  very 
recently.  Its  full  significance,  however,  has  been  only  lately 
understood. 

One  should  be  able  in  almost  all  cases  to  distinguish  the  chorion 
from  the  amnion.  The  chorion  has  a  rough  outer  surface  which  is 
due  to  the  portion  of  the  decidua  which  remains  attached  to  it,  the 
amnion,  on  the  other  hand,  is  smooth  on  both  sides  and  is  thinner 
but  stronger  than  the  chorion. 

In  further  examination  one  should  endeavor  to  decide  whether 
all  the  membranes  have  been  expelled  or  not.  There  should  be 
enough  present  to  have  enclosed  the  foetus,  making  some  allow- 
ance for  a  certain  amount  of  shrinking  due  to  their  elasticity.  In 
looking  for  the  layers  it  may  be  noted  that  the  chorion  wholly  or 
in  part  is  more  likely  to  be  left  in  the  uterus  than  the  amnion. 
When  the  chorion  has  come  away  the  amnion  is  not  likely  to  be 
left  behind.  In  a  certain  number  of  cases,  however,  the  amnion 
may  be  torn  away  from  the  edge  of  the  placenta  and  separated 
from  the  chorion  when  it  has  been  carried  down  as  a  bag  descend- 
ing far  in  advance  of  the  head. 

There  is  considerable  difference  of  opinion  among  eminent 
obstetricians  as  to  the  proper  procedure  when  there  is  simply  a 
suspicion  of  the  retention  of  a  portion  of  membranes  or  placenta. 

For  instance,  Galabin,  who  is  careful  and  conservative,  tells  us 
that  if  any  portion  of  the  placenta  or  membranes  appears  to  be 
absent  it  must  be  sought  for  within  the  uterus  and  removed. 
Jewett,  on  the  other  hand,  who  represents  the  views  of  a  large 
number  of  American  obstetricians,  expresses  the  opinion  that  frag- 
ments of  membranes  remaining  wholly  in  the  uterine  cavity  are, 
as  a  rule,  better  left  to  be  expelled  with  the  lochial  discharges 
unless  they  give  rise  to  haemorrhage.  We  should,  of  course,  in  all 
cases  prefer  to  be  certain  that  the  placenta  and  membranes  have 
been  expelled  entire.  In  cases  of  doubt  the  introduction  of  the 
hand  within  the  uterus,  the  exploration  of  the  cavity,  and  the 
removal  of  its  contents,  whether  they  be  bits  of  placenta,  mem- 


THIRD    STAGE    OF    LABOR  131 

brancs,  or  clots,  would  seem  to  be  the  correct  and  thorough  method. 

Unfortunately,  however,  such  introduction  of  the  hand  adds  very 
materially  to  the  danger  of  septicieniia. 

If  the  labor  has  been  properly  conducted  no  saphrophytic  or 
parasitic  (pathogenic)  microbes  will  have  been  introduced  into  the 
uterus,  and  consequently  small  fragments  of  membranes  and  pla- 
centa are  not  likely  to  cause  septicaemia.  One  is  not  justified, 
however,  in  leaving  large  portions  of  the  placenta  or  membranes 
within  the  uterine  cavity. 

The  following  rules  are  recommended : 

1.  When  one  suspects  that  small  portions  of  placenta  or  mem- 
branes are  retained  in  the  uterine  cavity  the  introduction  of  the 
hand  is  not  necessary. 

2.  When  one  suspects  or  is  certain  that  considerable  portions 
of  placenta  and  membranes  are  retained  the  hand  should  be  intro- 
duced and  the  uterine  contents  removed.  In  carrying  out  such 
procedure  it  is  necessary  to  use  both  antiseptic  and  aseptic  meth- 
ods as  to  the  hand  introduced,  the  vulva,  adjacent  parts,  and  the 
vaginal  canal.  In  certain  cases,  when  the  membranes  are  only  par- 
tially retained  within  the  uterine  cavity  and  a  certain  portion 
projects  into  the  vagina,  the  safest  procedure  is  to  seize  it  with  a 
dressing  forceps  and  extract,  using  torsion  carefully — as  recom- 
mended by  Durhssen. 

3.  If  on  the  second,  third,  or  fourth  day,  or  even  at  any  sub- 
sequent time,  there  is  reason  to  suspect  that  the  retained  debris  is 
causing  mischief,  and  especially  if  the  discharges  are  offensive,  the 
interior  of  the  uterus  should  be  thoroughly  explored  and  properly 
treated. 

The  Administration  of  Ergot. — Ergot  was  at  one  time  very 
commonly  administered  during  labor,  and  was  supposed  to  be 
fairly  safe  and  efficacious  in  the  latter  part  of  the  first  stage 
when  the  child  was  in  good  position,  the  presenting  part  low 
down,  and  the  soft  parts  well  dilated. 

I  remember  one  case  which  happened  during  my  first  year  of 
practise  in  Toronto.  The  patient  was  a  healthy  primipara.  The 
head  had  been  on  the  perinseum  for  something  like  two  hours ;  the 
parts  were  well  dilated.  My  proper  course  was  clear.  I  should 
have  used  the  forceps,  but  I  was  somewhat  timid,  and  the  patient 
and  her  husband  both  objected  to  the  use  of  "instruments."  I 
gave  one  dose  of  ergot,  and  a  second  in  fifteen  minutes  after.     In 


132  NOEMAL    LABOR 

due  time  I  noticed  a  strong  pain  coming  on.  This  rapidly  became 
more  severe.  I  soon  found,  to  my  dismay,  that  the  patient  was 
simply  having  one  extremely  severe  and  continuous  pain  (tonic 
contraction),  without  the  slightest  expulsive  action  on  the  part  of 
the  uterus.  Fortunately  I  had  sense  enough  to  apply  the  forceps 
at  once  and  deliver  the  child  without  any  difficulty. 

A  certain  proportion  of  obstetricians,  even  at  the  present  time, 
administer  ergot  before  the  expulsion  of  the  placenta.  In  a  fairly 
large  proportion  of  cases  it  is  probable  that  such  administration 
does  little  harm  or  good,  but  in  certain  cases  it  does  positive  harm. 
If  the  placenta  can  not  be  expelled  in  an  hour  it  is  either  adherent 
or  simply  retained.  For  adherent  placenta  ergot  is  absolutely 
useless;  for  simple  retained  placenta  ergot  is  likely  to  do  more 
harm  than  good,  because  it  may  produce  a  tightening  of  the  mus- 
cular fibers  near  the  cervix  which  will  cause  an  incarceration  which 
is  difficult  to  overcome.  The  contractions  caused  by  ergot  are 
tonic,  not  intermittent,  in  character.  Ergot  by  mouth  usually  acts 
in  fifteen  minutes ;  hypodermically  in  four  or  five  minutes. 

It  is  better  to  watch  the  uterus  for  one  hour  after  the  expulsion 
of  the  placenta.  It  is  not  necessary  during  this  time  to  use  any 
violence,  which  is  not  only  useless  but  harmful,  on  account  of  the 
extreme  discomfort  or  pain  which  is  produced. 

CARE    OF   THE    MOTHER    AND    BABE    IMMEDIATELY 
AFTER    LABOR 

TREATMENT  OF   THE   MOTHER 

As  external  tears  are  especially  dangerous  from  a  surgical 
standpoint,  it  is  important  that  the  vulva  and  adjacent  parts  be 
washed  or  bathed  with  great  care,  as  mentioned  in  the  Rules  for 
Antiseptic  Midwifery.  A  warm  antiseptic  solution  is  the  safest 
and  should  be  applied  as  gently  as  possible,  because  the  parts  are 
more  or  less  tender.  These  dressings  should  be  sufficiently  fre- 
quent. Some  physicians  direct  the  nurse  to  change  the  pads  and 
wash  the  parts  every  four  hours.  Such  a  rule  is  faulty  because  it 
is  frequently  misleading.  I  once  found  a  foul  smell  coming  from  a 
bed  three  days  after  labor.  On  examination  we  discovered  that 
the  discharges  had  passed  through  the  vulvar  pads  into  the  bed.  I 
was  surprised,  as  I  had  great  confidence  in  the  nurse,  and  remarked 


CAEE    OF    THE    MOTITEK    AND    BABE  133 

that  the  pads  had  not  been  changed  sufficiently  often.  She  told 
me  she  had  carried  out  the  routine  rule  prevailing  in  that  hospital 
and  had  changed  the  pads  every  four  hours. 

Each  vulvar  pad  should  be  removed  if  possible  before  it  becomes 
saturated.  If  even  a  slight  cjuantity  of  the  lochia  has  passed  into 
the  bed  the  sheet  should  be  replaced  and  the  mackintosh  or  rubber 
sheeting  washed.  The  frequency  of  the  dressings  should  depend 
largely  on  the  amount  of  the  lochial  discharges.  Numerous  changes 
may  be  required  during  the  first  twelve  or  twenty-four  hours. 

In  cleansing  the  hands  when  there  is  blood  on  them  it  is  better 
first  to  wash  in  cold  water;  soapy  water  does  not  dissolve  blood 
readily.  Clear  water  and  perhaps  a  nail-brush  should  be  used 
first,  and  water  with  soap  next. 

Injuries  to  the  Perinseum  and  Pelvic  Floor. — It  is  generally  under- 
stood, as  already  explained,  that  laceration  of  the  perinseum  is  apt 
to  occur.  It  is  not  so  generally  understood  that  laceration  of  the 
pelvic  floor  or  of  the  posterior  wall  of  the  vagina  is  also  apt  to  occur. 
These  injuries  are  discussed  more  fully  in  the  chapter  on  Operative 
Midwifery.  It  should,  however,  be  a  rule  in  every  case  to  make  a 
careful  examination  with  a  view  of  discovering  any  such  injuries 
and  also  their  extent  when  they  exist.  When  in  doubt  as  to  the 
extent  of  injuries  to  the  pelvic  floor  the  examination  can  be  best 
carried  out  after  placing  the  woman  in  the  dorsal  position  across 
the  bed  with  the  thighs  flexed  upon  the  abdomen.  It  is  better  to 
have  a  nurse  or  other  assistant  hold  the  labia  apart.  One  can  then 
cleanse  the  posterior  wall  of  the  vagina  with  pledgets  of  cotton 
soaked  in  lysol  solution,  and  leave  a  plug  in  the  vagina  to  prevent 
the  blood  from  running  over  this  region  during  the  inspection.  In 
this  way  the  tear  of  the  perineal  body,  and  also  of  the  posterior 
vaginal  wall  or  pelvic  floor,  can  easily  be  detected  and  examined. 

Abdominal  Bandage. — An  abdominal  bandage  is  applied  after 
the  removal  of  soiled  clothing.  There  has  been  considerable  differ- 
ence of  opinion  in  the  past  as  to  the  advisability  of  applying  a 
binder.  Something  like  forty  years  ago  certain  obstetricians  in 
Paris  dispensed  with  its  use.  Shortly  after  this  Gaillard  Thomas 
advised  obstetricians  not  to  use  an  abdominal  bandage.  It  is  now 
generally,  but  not  universally,  admitted  that  a  binder  should  be 
applied  in  all  cases  immediately  after  labor.  It  adds  much  to  a 
woman's  comfort  and  allows  her  to  turn  upon  her  side  with  greater 
safety.    It  should  be  worn  not  merely  while  she  is  confined  to  bed, 


134  NOEMAL   LABOR 

but  for  some  time  after  she  begins  to  sit  up.  A  bandage  is  gener- 
ally ready  at  hand,  but  if  not,  one  may  choose  unbleached  muslin 
or  ordinary  factory  cotton.  It  should  be  long  enough  to  surround 
the  body  with  a  few  inches  to  spare  and  wide  enough  to  extend 
from  the  ensiform  process  to  a  point  slightly  below  the  trochanters. 

In  adjusting  the  bandage  seize  the  near  end  between  the  thumb 
and  two  fingers  of  the  left  hand  and  draw  the  further  portion 
smoothly  over  it  with  the  right  hand,  then  hold  the  two  ends  with 
the  left  hand  and  insert  the  safety-pins  with  the  right.  Insert  the 
pins  from  below  upward,  taking  care  to  draw  the  bandages  as 
tightly  as  possible  before  inserting  the  lower  two  or  three  pins. 
The  intervals  between  the  pins  should  be  about  two  inches.  After 
inserting  the  lower  two  or  three  pins,  I  sometimes  introduce  the 
next  pin  immediately  above  the  fundus  uteri  and  afterward  put 
one,  two,  or  three  pins  in  the  interval  which  has  been  left.  About 
six  to  eight  pins  should  be  used  altogether.  It  is  better,  especially 
in  country  practise,  where  one  has  not,  as  a  rule,  many  skilled 
nurses,  to  make  it  a  point  to  apply  the  binder  the  first  time  himself, 
otherwise  many  women  think  they  are  neglected.  Such  being  the 
case  it  is  very  important  that  skill  be  shown  in  the  application  of 
the  binder.  In  carrying  the  bandage  under  the  patient's  back  it 
is  well  to  roll  one-half  and  then  pass  the  roll  under  the  patient's 
back  to  the  opposite  side,  then  unroll.  One  should  take  care  that 
there  are  no  wrinkles  in  the  binder  under  the  patient's  back. 

Some  are  in  the  habit  of  placing  a  pad  made  of  folded  diapers, 
or  something  of  that  sort,  over  the  abdomen  before  fastening  the 
bandage  with  the  idea  of  producing  compression  of  the  uterus. 
This  is  likely  to  do  more  harm  than  good,  because  the  pad  thus 
applied  is  apt  to  slip  and  then  press  the  uterus  out  of  place. 

In  some  cases,  however,  when  there  is  considerable  haemorrhage 
following  the  relaxed  condition  of  the  uterus,  especially  in  a  thin 
woman,  it  may  be  well  to  use  something  in  the  form  of  a  pad, 
which  is  likely  to  assist  in  keeping  the  uterus  contracted.  The 
best  method  of  doing  this  is  the  one  which  used  to  be  adopted  by 
James  Ross,  of  Toronto.  Make  three  rolls  of  three  towels  about 
as  thick  as  the  wrist,  place  one  of  them  transversely  just  above  the 
fundus  uteri  and  the  other  two  at  the  sides  of  the  uterus  and  then 
fasten  the  bandage  firmly  over  them.  In  this  way  the  uterus,  as 
Parvin  expresses  it,  is  enclosed  in  a  box,  the  Hd  of  the  box  being 
the  portion  of  the  bandage  in  front  of  the  abdomen. 


CAEE  OF  THE  MOTHER  AND  BABE     135 

After  the  application  of  th(>  Imndago  and  tlic  adjnstniont  of  the 
night-dress  the  patient  should  be;  dry  and  comfortable.  One  should 
make  it  a  point  to  carry  out  all  these  details  in  as  thorough  and 
kindly  a  manner  as  possible.  If  a  physician  is  careless  and  in- 
different and  inclined  to  leave  all  the  details  to  the  nurse,  he  will 
certainly  not  have  pleased  his  patient,  and  I  think  will  not  have 
done  his  duty. 

It  is  a  good  rule  to  remain  an  hour  in  the  house  after  the  delivery 
of  the  placenta.  One  should  always  keep  in  mind  the  danger  of 
haemorrhage.  Post-partum  haemorrhage  is  generally  due  to  relaxa- 
tion of  the  uterus,  but  also  occasionally  to  laceration  of  the  cervix. 
Whatever  be  the  cause  one  should  always  stay  with  his  patient 
until  such  haemorrhage  is  checked. 

There  is  an  old  rule  that  one  should  not  leave  the  house  if  the 
pulse  is  100  or  over.  It  is  right  to  consider  a  rapid  pulse  as  a 
danger  signal,  especially  if  it  becomes  rapid  somewhat  suddenly 
within  a  short  time  after  the  completion  of  labor.  Sometimes, 
however,  the  pulse,  for  some  reason  or  other,  is  100  or  thereabouts 
during  the  latter  part  of  labor  and  remains  rapid  for  some  time 
after  without  any  serious  accompanying  symptoms. 

MANAGEMENT  OF  THE   BABE 

Dressing  the  Cord, — It  is  better  to  apply  some  antiseptic  solu- 
tion, such  as  one  of  lysol,  wipe  dry  and  then  surround  the  cord 
with  absorbent  cotton.  This  will  be  kept  in  position  by  the  ab- 
dominal bandage,  which  should  be  applied  until  the  cord  has  come 
away.  The  stump  or  wound  of  the  cord  may  be  covered  by  uniting 
the  edges  of  the  skin  of  the  cord  (formerly  called  the  amniotic 
sheath)  with  a  running  kangaroo  or  catgut  suture. 

The  nurse  generally  looks  after  the  babe  from  the  time  that  it 
is  lifted  from  the  bed.  Before  giving  the  babe  in  charge  of  the 
nurse,  however,  for  its  first  washing  one  should  examine  it  very 
carefully  with  the  following  points  in  view : 

Examine  the  cord  for  bleeding. 

Examine  the  whole  body  for  birthmarks,  etc. 

Examine  the  head  for  meningocele,  etc. 

Examine  the  back  for  spina  bifida,  etc. 

Examine  the  Hmbs  for  talipes  and  other  deformities. 

Examine  for  imperforate  anus. 


136 


NORMAL    LABOR 


Apparent  Death  of  Babe. — 1.  When  the  face  is  dark  in  color  and 
swollen,  with  perceptible  action  of  the  heart  {asphyxia  livida),  the 
case  is  favorable.  2.  When  the  face  is  pale  {asphyxia  pallida),  limbs 
flaccid  and  no  apparent  action  of  heart,  the  case  is  unfavorable. 


Fig.  88. — Cutting  the  Cord. 

Treatment  for  Asphyxia. — The  physician  should  adopt  a  definite 
line  of  treatment  for  the  purpose  of  resuscitating  a  child  partially 
asphyxiated  or  apparently  dead.  First,  slap  the  front  and  back 
of  the  chest  and  then  invert  the  child,  holding  it  by  the  feet  for  two 
or  three  seconds.  If  these  procedures  fail,  employ  artificial  res- 
piration, of  which  the  best  methods  are  those  of  Sylvester,  Byrd, 
and  Laborde. 

Atelectasis,  a  persistence  of  the  foetal  condition  of  the  lungs,  is 
frequently  associated  with  and  may  be  the  main  cause  of  the 
asphyxia.  This  condition  does  not  necessitate  any  change  in  our 
methods  of  resuscitation. 

Fatal  death.  Chapin  distinguishes  between  the  dead-born  and 
the  still-born  babe.  In  the  former  the  respirations  and  reflexes  are 
absent,  the  pupils  are  widely  dilated  and  the  rectal  temperature 
rapidly  falls  to  10°  or  15°  below  normal. 


DESCRIPTION    OF    METHODS    OF    ARTIFICIAL    RESPIRATION 

Sylvester's  Method.  Place  child  on  its  back,  with  a  small 
cushion  under  its  shoulders,  so  as  to  incline  head  slightly  back- 
ward.    Stand  behind  the  child  and  seize  an  arm  above  the  elbow 


CARE    OF    THE    :M0THER    AX  I)    P.A?,E 


137 


with  each  hand.  Raise  arms  slowly  above  the  head,  at  the  same 
time  rotating  each  humerus  slightly  outward.  Keep  them  raised 
two  or  three  seconds. 

Next  bring  down  the  arms  and  press  gently  against  side  of  chest 
two  or  three  seconds. 

Repeat  these  movements. 

ByrcVs  Method.  Lay  the  child  on  its  back  upon  the  palmar 
surfaces  of  your  outstretched  hands.  Elevate  the  radial  edges  of 
your  hands  so  as  to  double  the  child's  trunk  upon  itself — to  cause 
expiration.  Then  lower  the  radial  edges  well  below  the  level  of 
the  ulnar  borders  of  the  hands  so  as  to  extend  the  child's  body — 
to  cause  inspiration.     Repeat  these  movements. 

Laborde's  Method  of  Rhythmic  Tongue  Traction.  Seize  tongue 
with  catch  forceps  or  by  finger  and  thumb  wrapped  in  a  piece  of 


Fig.  89. — Artificial  Respiration.     Sylvester's  Method.      (First  Part.j 


cloth,  and  strongly  draw  it  out  of  the  mouth,  then  allow  it  to  fail 
back  into  its  normal  position. 

Repeat  fifteen  times  in  a  minute. 

In  using;  these  methods  the  different  movements  should  not  be 


138 


NOEMAL   LABOE 


made  too  rapidly.  Once  in  three  seconds  is  sufficiently  often  for  the 
methods  of  Sylvester  and  Byrd,  and  once  in  four  seconds  for  that 
of  Laborde.  The  methods  of  Sylvester  and  Laborde  may  be  used 
in  conjunction,  one  person  drawing  out  the  tongue  while  the  other 


Fig.  90. — Artificial,  Respiration.     Sylvester's  Method.    (Second  Part.) 


is  raising  the  arms  over  the  head.  Laborde 's  method  may  be  used 
while  the  babe  is  held  in  a  warm  bath.  These  methods  are  useful, 
especially  for  full-term  babes.  Great  care  should  be  used  in  em- 
ploying them  for  premature  infants,  for  whom  we  often  have  to 
rely  chiefly  on  the  effects  of  heat.  It  is  often  necessary  to  clear 
the  mucus  out  of  the  throat.  This  may  be  done  with  the  simple 
rubber  bulb  and  tube. 

Direct  Insufflation. — Mouth  to  mouth  method.  Place  the  child 
on  its  back,  with  head  slightly  extended.  Cover  its  face  with  a 
handkerchief  or  towel,  draw  a  full  breath  and  blow  gently  the  first 
portion  of  the  expired  air  into  the  mouth,  one  hand  at  the  same 
time  pressing  over  the  epigastrium  to  prevei;it  the  air  from  passing 
into  the  stomach.  Do  not  keep  the  nostrils  closed,  as  sometimes 
recommended,  but  leave  them  open  to  act  as  safety  valves.     Too 


CARE  OF  THE  MOTHEE  AND  BABE 


139 


much  force  in  blowing  air  into  the  lungs  injures  the  air  cells. 
Catheterization  of  the  trachea  is  dangerous  because  it,  too,  inj  ures 
the  air  cells. 

While  carrying  out  these  various  procedures  the  nurse  may  be 
directed  to  bring  two  large  basins  or  foot-baths — one  containing 
hot  and  the  other  cold  water.  Put  the  child  alternately  into  the 
two  basins,  taking  care  that  the  water  is  not  too  hot  and  do  not 
leave  it  too  long  in  the  cold  water.  If  the  face  is  very  livid  it  is 
well  to  cut  the  cord  and  let  some  blood  escape  before  tying.  Some 
advise  hypodermic  injections  of  whisky — 10  to  20  drops — and 
strychnine  y^y  gr.  Their  utility  is  doubtful,  but  a  saline  enema — 
2  to  4  ounces,  at  a  tem- 
perature of  110°,  some-  ~ 
times  has  a  good  effect. 

Washing  the  Babe. — 
The  nurse  should  use  warm 
water  and  bland  "baby" 
soap  and  may  use  olive  oil 
to  assist  in  removing  the 
vernix  caseosa. 

If  the  babe  is  prema- 
ture and  very  weak  it  is 
better  to  anoint  it  with  oil 
and  wrap  in  cotton  wool 
without  dressing  for  days 
(see  page  167). 

Dressing  the  Babe. — 
The  Gertrude  baby  suit  is 
a  reform  method  of  cloth- 
ing for  infants,  designed  by 
Dr.  Grosvenor,  of  Chicago, 
and  introduced  into  To- 
ronto by  Miss  Snively. 

The  Gertrude  baby  suit 
consists  of  three  garments 

and  diapers  for  the  day,  viz.,  dress,  middle  garment,  undergar- 
ment, and  diaper;  a   nightgown  and  diaper  for  the  night. 

The  undergarment — i.e.,  the  garment  next  the  skin — is  made 
of  canton  flannel  or  fine  flannel  or  flannelette,  cut  in  princess  style, 
and  reaching  from  the  neck  to  ten  inches  below  the  feet,  being 


Fig.   91.- 


-Aetificial  Respiration. 
Method.     (First  Part.) 


Byrd's 


140 


NOEMAL    LABOE 


altogether  25  inches  long;   sleeves  to  the  wrists;   a  tie  and  one 
button  behind. 

The  middle  garment  is  made  of  baby  flannel,  same  pattern  as 
the  undergarment,  but  without  sleeves,  with  neck  and  armholes 

scalloped,  not  bound,  and 
with  two  buttons  behind 
at  the  neck.  It  may  be 
embroidered  in  any  way 
desired. 

The  dress  or  outer  gar- 
ment is  made  after  the 
same  pattern  as  the  other 
garments,  but  about  an 
inch  longer.  Any  style  of 
dress,  however,  may  be 
used. 

The  diapers  are  of  two 
sizes,  18  X  18  and  10  X  10 
inches,    the    larger    to    be 
folded    diagonally.     The 
addition     of    the    smaller 
where  most  needed  saves 
unnecessary  thickness  over 
the  hips  and  kidneys.    Can- 
ton flannel  is  the  material 
recommended.     The  night- 
gown is  similar  to  the  un- 
dergarment in  pattern  and  made  of  baby  flannel,  but  may  be  a 
httle  longer.     All  seams  should  be  smooth  and  the  hems  at  the 
neck,  wrist,  and  bottom  on  the  outside. 

This  method  of  dressing  the  baby  commends  itself  because  of  its 
simplicity. 

It  does  not  interfere  with  the  ordinary  outside  dress,  which  may 
be  made  in  such  styles  as  taste  may  dictate. 
The  advantages  claimed  are : 

First. — All  the  clothing  hangs  from  the  shoulders. 
Second. — There  are  no  bands  or  bandages  to  interfere  with  the 
freedom  of  the  thoracic,  abdominal,  and  pelvic  organs. 

Third. — There  is  no  pinning  blanket  or  barrowcoat,  and  no 
shoulder  blanket. 


Fig.  92. 


-Artificial  Respiration.     Byrd's 
Method.     (Second  Part.) 


CAEE  OF  THE  MOTHEK  AXD  BABE      141 

Fourth. — There  is  evenness  of  the  covering  of  the  horly  and  no 
difference  between  that  of  the  shoulders  and  other  parts. 

In  dressing  the  infant  the  three  garments  are  placed  together — 
sleeve  within  sleeve — the  baby,  face  downward,  the  combined 
garments  are  slipped  over  the  head,  the  arms  placed  in  the  sleeves, 
and  the  garments  fastened  behind.  At  night  the  three  combined 
garments  are  removed  together  and  the  flannel  night-dress  replaces 
them.  No  stockings  or  socks  are  worn  night  or  day.  There  should 
be  no  fixed  rules  as  to  fabrics  used.  A  fine  all-wool  stockinet  of 
soft  texture  answers  admirably  for  the  undergarment. 

The  designer  proposes  to  use  no  abdominal  binder  on  the  babe. 
I  consider  it  almost  a  necessity,  until  the  cord  has  become  sepa- 
rated. I  also  prefer  some  sort  of  belly-band  to  be  worn  during  the 
greater  part  of  the  time  for  one  or  two  years.  It  affords  great 
protection  especially  during  the  late  summer  and  autumn  months 


Fig.  93. — Gertrude  B.\by  Stht. 

The  undergarment  in  the  center,  the  middle  garment  on  the  left,  the  outer 
garment  on  the  right. 

when  young  children  are  subject  to  bad  forms  of  diarrhoea  and 
dysentery.  The  tight  band  is,  however,  objectionable  in  some  re- 
spects, because  it  "interferes  with  the  freedom  "  of  internal  organs. 
My  preference  is  to  replace  the  band  after  the  separation  of  the 
cord  with  a  cylindrical  knitted  or  woven  band,  which  furnishes  the 
protection  without  causing  undue  compression.  The  flannel  skirts 
afford  sufficient  protection  to  the  feet.  The  woolen  socks  com- 
monly used  can  only  be  retained  by  the  use  of  a  band  around  the 
ankle,  which  may  interfere  with  circulation  in  the  feet. 


142  NORMAL    LABOE 


ANESTHETICS  IN  LABOR 

Importance  of  Chloroform. — Chloroform  easily  takes  prece- 
dence over  all  other  anaesthetics  in  labor.  Sir  James  Y.  Simpson 
proved,  early  in  1847,  that  sulphm^c  ether  could  be  safely  inhaled 
for  the  rehef  of  pain  in  labor,  and,  later  in.  the  same  year,  that 
chloroform  might  be  inhaled  in  a  similar  way  and  with  similar 
results.  For  some  years  he  strongly  advised  the  use  of  this  anaes- 
thetic as  a  routine  practise  in  the  treatment  of  all  cases  of  labor. 

This  new  treatment  was 
stubbornly  opposed,  espe- 
cially in  Great  Britain  and 
the  United  States.  The  ob- 
stetricians of  London  were 
^^gf  probably  the    most   stren- 

uous in  their  opposition  for 
a  short  time.     This  perhaps 
,  •  should     cause     no    special 

•^  I  "  surprise,  because  we  often 

*  find    that    the    Edinburgh 

'^'*'%f-  leaven  leaveneth  the  Lon- 

*-' '  don  lump  somewhat  slowly. 

However,  we  are  told  that 
Her  Majesty,  Queen  Vic- 
toria, had  faith  in  Simpson 
and  insisted  upon  her  phy- 
sicians adopting  his  meth- 
FiG.  94.— Sir  James  y.  Simpson.  ^jg  ^^  her  subsequent  con- 

finements. This  helped  to 
popularize  the  administration  of  anaesthetics  during  labor  even 
in  conservative  London.  Chloroform  was  first  administered  to 
Queen  Victoria  by  Snow  in  her  seventh  labor  in  April,  1853,  when 
Prince  Leopold  was  born.  The  medical  attendants  in  charge  were 
Locock,  Grant,  and  Ferguson. 

Chloroform  •  properly  administered  is  comparatively  safe  in 
labor.  Clinical  experience  teaches  that  it  is  safer  in  obstetrical 
practise  than  in  any  other  branch  of  medicine  or  surgery.  And 
yet  I  do  not  wish  to  convey  the  impression  that  it  is  perfectly  safe 
and  may  be  administered  to  any  extent  in  a  case  of  labor.  It  some- 


ANAESTHETICS    IN    LABOR  143 

times  stops  the  uterine  contractions  and  thus  prolongs  the  labor. 
It  sometimes  predisposes  to  post-i)artum  hicmorrhage. 

The  administration  of  chloroform  too  early  in  labor,  as,  for  in- 
stance, in  the  first  stage,  and  in  too  large  a  quantity,  is  always 
dangerous.  It  fortunately  happens  that  a  death  from  chloroform 
during  labor  is  almost  .unknown,  excepting  when  the  anesthetic 
has  been  administered  in  an  exceedingly  careless  and  negligent  way. 

It  is  also  an  interesting  fact  that  chloroform  in  labor  almost 
never  causes  vomiting,  whether  administered  to  the  obstetrical 
degree  only  or  to  the  surgical  degree. 

Administration  of  Chloroform. — In  considering  the  proper 
method  of  administering  this  amesthetic  it  is  well  to  observe  cer- 
tain rules. 

1.  Never  administer  it  during  the  first  stage.  Some  exceptions 
may  arise,  as,  for  instance,  when  there  is  extreme  rigidity  of  the 
cervix  due  to  spasm.  In  other  words,  in  a  normal  labor  never 
administer  the  chloroform  until  after  the  completion  or  about  the 
time  of  the  completion  of  the  first  stage.  In  an  abnormal  labor, 
however,  there  are  exceptional  conditions  which  require  special 
treatment. 

2.  Administer  the  chloroform  only  during  the  pain,  and  only  to 
Avhat  is  called  the  obstetrical  degree.  By  the  obstetrical  degree  we 
mean  that  a  patient  is  never  completely  anaesthetized — that  is, 
she  never  becomes  totally  unconscious.  The  most  common  way 
of  administering  it  now  is  by  an  Esmarch  mask  or  something  of 
that  sort.  This  should  be  placed  over  the  nose  and  mouth.  The 
chloroform  should  be  in  a  proper  "dropper"  bottle.  This  may 
be  improvised  by  simply  cutting  a  canal  in  the  side  of  a  cork  (or 
two  canals — one  on  either  side)  with  a  penknife,  and  then  putting 
the  cork  in  the  bottle  sufficiently  tightly  to  let  the  chloroform  come 
through  drop  by  drop.  It  is  better  to  put  a  little  vaseline  or  cold 
cream  over  the  nose  and  chin  at  the  base  of  the  mask  to  prevent 
burning  from  the  chloroform. 

At  the  commencement  of  a  pain  and  during  the  pain  pour  on  the 
mask  three  to  eight  drops  of  chloroform.  As  soon  as  the  pain  has 
ceased  remove  the  mask  from  the  face. 

The  patient,  during  such  administration,  is  very  apt  to  move 
her  head,  sometimes  quite  suddenly.  Be  careful,  under  such  cir- 
cumstances, not  to  pour  the  chloroform  into  the  patient's  eye 

instead  of  on  the  mask. 
11 


144  NORMAL   LABOE 

3.  Administer  the  chloroform  a  httle  more  freely  toward  the 
end  of  the  second  stage,  especially  while  the  head  is  passing  the 
rima  pudendi. 

4.  Administer  no  chloroform  after  the  head  is  expelled. 
Chloroform  will  require  to  be  administered  to  the  surgical  degree 

in  most  obstetrical  operations,  whether  performed  during  or  after 
labor.  It  should  be  remembered,  at  the  same  time,  that  the 
relative  safety  of  chloroform  in  parturition  ceases  with  the  birth  of 
the  child.  It  may  be  considered  advisable,  under  certain  con- 
ditions, to  administer  ether  instead  of  chloroform,  but  of  that 
more  hereafter. 

Forceps  delivery  is  so  common  in  uncomplicated  labors  that  a 
brief  reference  may  be  made  to  the  operation  at  the  present  time. 
During  this  operation  the  patient  should  be  completely  anaesthe- 
tized, or  she  should  get  no  anaesthetic  at  all.  If  ''under  "  only  to 
the  obstetrical  degree  the  patient  may  plunge  about  to  such  an 
extent  that  the  forceps,  when  partly  or  completely  applied,  become 
a  source  of  danger. 

After  the  administration  of  chloroform  in  the  slighter  degree  for 
a  certain  time  the  contractions  may  become  weaker  and  less  fre- 
quent and  progress  may  stop.  Under  such  circumstances  it  is 
better  to  stop  the  administration  of  the  anaesthetic  for  a  time. 
This  is  not  always  easy  to  do,  because  the  patient,  after  obtaining 
some  relief  from  the  anaesthetic,  always  clamors  for  more  and  cer- 
tainly objects  strongly  to  suffering  any  pain  without  getting  a  ' '  few 
whiffs"  at  least.  Under  such  circumstances,  one  may  say  that 
he  is  compelled  to  stop  the  chloroform  because  it  is  interfering 
with  the  progress  of  labor.  The  other  alternative  is  to  have  the 
patient  thoroughly  anaesthetized  and  deliver  with  forceps. 

It  should  be  a  positive,  rule  when  the  patient  is  completely 
anaesthetized  to  get  an  expert  anaesthetist,  or  at  least  a  licensed 
practitioner,  to  administer  the  anaesthetic. 

Ether. — It  is  generally  understood  that  chloroform  is  more  suit- 
able for  obstetrical  purposes  than  ether,  especially  when  one  only 
wishes  to  anaesthetize  the  patient  to  the  obstetrical  degree.  The 
ether  is  less  pleasant  (or  more  unpleasant)  to  inhale  and  is  not  apt 
to  cause  bronchial  irritation.  Most  obstetricians  will  also  agree 
that  chloroform  is  preferable  for  forceps  dehvery.  Many,  how- 
ever, prefer  ether  for  protracted  operations  during  labor  or  after 
labor,  such,  for  instance,  as  caesarean  section,  symphysiotomy,  and 


ANiESTHETICS    IN"   LABOR  145 

post-partum  operations  for  lacerations  of  the  perinseum  and  pelvic 
floor,  if  there  be  no  bronchial  or  kidney  disease. 

Chloroform  and  Ether  Combined. — During  the  last  few  years  I 
frequently  coiubinc  chlorofonu  and  ether,  using  1  ounce  of  chloro- 
form to  2  ounces  of  ether,  or  equal  parts  by  bulk  (as  recom- 
mended to  me  by  Stevenson).  I  carry  in  my  satchel  one  2  oz. 
bottle  of  plain  chloroform  and  another  2  oz.  bottle  containing  a 
mixtun;  of  chloroform  and  ether.  I  frequently  administer  the 
plain  chloroform  for  a  while  and  toward  the  end  of  the  second  stage 
put  aside  the  plain  chloroform  and  use  the  combined  mixture. 

Spinal  anaesthesia  by  means  of  medullary  cocainization,  which 
was  recommended  two  or  three  years  ago,  is  now  generally  re- 
garded as  dangerous. 

Chloral. — Although  discovered  by  Liebig  in  1832  chloral  was 
not  used  in  medicine  until  1869.  Early  in  1870  Simpson  com- 
menced to  administer  it  to  women  in  labor  and  thought  that  it 
relieved  pain  without  interfering  with  uterine  contractions. 

One  of  the  most  enthusiastic  advocates  of  the  use  of  chloral  in 
normal  labor  was  Playfair,  who  first  recommended  it  something 
like  thirty  years  ago.  He  considered  it  peculiarly  adapted  to  the 
first  stage  of  labor  when  the  patient  is  suffering  greatly  and  the  os 
is  rigid  and  dilating  very  slowly  or  not  at  all.  He  advised  15 
grain  doses  of  chloral  every  twenty  minutes  until  three  doses  are 
given.  The  effect  of  this  is  that  the  patient  becomes  quite  drowsy 
and  dozes  between  the  pains  and  wakens  as  each  contraction  be- 
gins. It  may  be  necessary  to  give  a  fourth  dose  at  a  longer  inter- 
val, say  an  hour  after  the  third,  but  rarely  more  than  a  dram  is 
required  in  the  whole  labor.  About  four  or  five  years  ago  Play- 
fair,  at  a  medical  meeting  in  London,  reported  his  views  as  to  the 
administration  of  chloral  and  stated  that  after  more  than  twenty- 
five  years  of  experience  in  its  use  he  still  thought  as  favorably  of 
it  as  ever. 

After  using  this  remedy  in  the  way  described  by  Playfair  for 
about  twenty- five  years,  I  can  say  that  it  answers  admirably  in  a 
certain  proportion  of  cases,  and  I  have  often  wondered  why  it  was 
not  more  generally  used  by  the  profession. 


CHAPTER  VIII 
THE  PUERPERAL  STATE 
GENERAL  CONDITIONS 

As  before  stated,  it  is  often  difficult  to  distinguish  between  the 
physiological  and  pathological  in  obstetrics.  Especially  is  this  the 
case  in  connection  with  puerperality,  or  the  puerperal  state. 
During  the  puerperium  we  find  a  variety  of  physiological  condi- 
tions which  might,  under  other  circumstances,  be  considered  patho- 
logical. This  has  been  well  pointed  out  by  Schroeder  and  Lusk, 
the  latter  of  whom  uses  the  following  words :  ' '  Thus  the  exfolia- 
tion of  the  decidua  and  the  copious  serous  exudation  with  the 
abundant  formation  of  young  cells,  which  accompanies  the  develop- 
ment of  the  new  mucous  membrane,  would  elsewhere  be  regarded 
as  characteristic  features  of  catarrhal  inflammation.  The  acute 
degeneration  of  the  uterus  presents  a  phenomenon  which,  when  re- 
peated in  any  other  organ  of  the  body,  would  prove  speedily  fatal. 
The  thrombus  formation  in  the  open  placental  vessels  possesses  no 
corresponding  physiological  analogue.  Again,  the  torn  vessels 
may  lead  to  haemorrhage,  while  the  traumata,  which,  even  in  nor- 
mal labor,  result  from  parturition,  the  ease  with  which  deleterious 
materials  are  absorbed  by  the  wide  lymphatic  interspaces,  the 
serous  infiltration  of  the  pelvic  tissues,  the  exaggerated  size  of  the 
lymphatics  and  veins,  create  a  predisposition  to  innumerable  forms 
of  disease.  The  nicety  of  the  balance  between  normal  and  morbid 
conditions  renders  it  peculiarly  necessary  for  the  practitioner  to 
make  himself  familiar  with  the  physiological  limits  of  the  phenom- 
ena of  childbed." 

And  yet,  if  we  do  not  interfere  with  Nature's  methods,  the  won- 
derful changes  included  under  the  term  involution  take  place  as  a 
matter  of  course  after  normal  labors  in  the  great  majority  of  cases ; 
and  the  healthy  young  woman  becomes,  at  the  termination  of  her 
puerperium,  as  vigorous  and  strong  as  she  was  previous  to  her 
146 


GENERAL    CONDITIONS 


147 


pregnancy.  It  is  not  strictly  true  that  all  the  organs  and  tissues 
are  restored  to  their  ori^itial  condition.  The  uterus,  after  preg- 
nancy and  labor,  is  n(>ver  ((uitc  the  same  as  the  nulliparous  uterus. 
The  hymen  and  fourchette  arc  almost  invariably  torn  during  labor 
and  Nature  does  not  restore  them.  However,  the  difference  be- 
tween the  healthy  uterus  after  labor  and  that  before  pregnancy  is 
of  no  account  practically,  and  tears  of  the  hymen  and  fourchette 
do  not  as  a  rule  produce  serious  consequences  under  aseptic  or 
antiseptic  methods. 

It  is  generally  considered  that  the  puerperium  lasts  about  six 
weeks.     While  this  is  not  strictly  true  it  is  generally  accepted  as  a 


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70 

70 

Fig.  95. — Chart  showing  Normal  Involution  Line,  Temperature,  and 

Pulse-rate. 

Column  on  right  shows  scale  in  inches  and  centimeters.    S'.  P.  is  symphysis  pubis. 


fact  by  obstetricians.  What  is  the  full  meaning  of  involution  after 
six  weeks?  As  expressed  by  Robb,  it  means  that  after  six  weeks 
the  normal  functions  of  the  non-impregnated  genitalia,  namely, 
menstruation  and  conception,  can  begin  again.  While  menstrua- 
tion is  rare  in  nursing  women  so  early  after  labor,  it  is  a  fact  that 
it  is  possible  for  them,  from  this  time  forward,  to  conceive  again, 
the  possibility  becoming  greater  every  month. 

Involution  of  the  Uterus. — This  may  be  briefly  defined  as  the 
process  by  which  the  uterus  resumes  its  ordinary  condition  after 
labor.  The  rapidity  of  the  diminution  in  the  size  of  the  uterus 
during  the  first  two  weeks  9,fter  labor  is  remarkable,     After  the 


148 


THE    PUERPERAL    STATE 


expulsion  of  the  placenta  the  uterus  is  strongly  anteflexed,  the 
fundus  lying  against  the  abdominal  wall.  The  anteflexion  increases 
somewhat  during  the  first  three  weeks  of  the  puerperium  and  is 
probably  a  part  and  an  important  part  of  Nature's  provision  for 
drainage  of  the  lochia.  After  four  weeks  the  uterus  gradually  re- 
turns to  its  normal  shape.     The  superficial  layer  of  the  mucosa 


107° 
106° 
105° 
104° 
103° 
102° 
101° 
100° 
99°/ 

/ 

i 

1- 

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Pulse 

E 

81 

86 

78 

74 

80 

70 

82 

78 

68 

72 

100 

78 

72 

70 

88 

90 

92 

76 

88 

78 

81 

80 

76 

120 

98 

98 

76 

74 

Fig.  96. — Chart  showing  Abnormal  Involution  Line. 
Rise  of  temperature  from  emotional  cause. 


(the  cellular  layer),  which  is  in  contact  with  the  decidua,  is  gener- 
ally thrown  off  with  the  membranes,  forming  a  part  of  what  we 
call  the  chorion.  The  deeper  layer  (the  glandular  layer)  remains 
behind,  and  from  it  is  developed  the  new  endometrium  in  about 
four  to  six  weeks. 

The  Involution  Line.  Daily  measurements  of  the  distance  of 
the  fundus  uteri  above  the  symphysis  pubis  should  be  taken.  By 
marking  the  position  of  the  fundus  from  day  to  day  we  obtain  what 
is  called  in  Queen  Charlotte's  Hospital  the  involution  line.  We  have 
had  this  line  traced  on  all  our  charts  at  the  Burnside  during  the  last 
three  years.  The  fundus  descends  more  rapidly  in  the  primipara 
than  in  the  multipara,  the  difference  being  on  an  average  one  or 
two  days  in  favor  of  the  former.  .  It  reaches  the  top  of  the  sym- 
physis before  or  on  the  eighth  day  in  70  per  cent,  of  primiparse,  and 
only  about  40  per  cent,  of  multiparse.     It  reaches  the  symphysis 


GENEKAL    CONDITIONS 


149 


before  or  on  the  tenth  day  in  the  majority  of  multipara.  In  both 
primiparse  and  multipane  the  time  may  vary  from  five  to  twelve 
days  without  any  apparent  abnormality.  We  attach  much  im- 
portance to  the  involution  line  in  the  Jiurnside  and  also  in  private 
practise. 

The  involution  of  the  vagina,  the  process  by  which  the  vagina 
resumes  its  ordinary  condition  of  after  labor,  is  probably  slower 
than  that  of  the  uterus  and  is  complete  in  about  eight  weeks. 

Chill  or  Rigor. — The  patient  is  very  apt  to  have  a  rigor  or  chill 
toward  the  end  of  labor  or  after  the  completion  of  labor.  It  gen- 
erally lasts  from  a  few  minutes  to  a  quarter  of  an  hour  and  is  not 
accompanied  by  any  change  in  the  pulse  or  temperature.  When 
a  patient  is  seized  with  a  chill  the  nurse  should  put  on  a  little 


F. 

107" 

106° 

105° 

104° 

103° 

102° 

101' 

100° 

93° 

98° 

87° 

, 

6 

TJi 

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k' 

\^y 

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'sA 

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/^ 

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U-. 

M 
Pulse 
E 

72 

70 

71 

72 

72 

74 

70 

72 

68 

70 

72 

68 

70 

Si 

78 

80 

76 

78 

88 

84 

78 

78 

78 

84 

8U 

72 

72 

Fig.  97. — Abnormal  Involution  Line. 
Slight  subinvolution  caused  at  first  apparently  by  distended  bladder, 
administration  of  ergot  appeared  to  assist  involution. 


The 


extra  covering  and  the  doctor  should  encourage  her  by  telling  her 
that  it  means  nothing  serious,  but  is  quite  a  common  occurrence 
after  labor. 

After-pains  are  so  common  that  they  may  generally  be  consid- 
ered as  physiological.  They  are  not  so  apt  to  occur  after  first 
labors  and  frequently  grow  steadily  worse  after  succeeding  labors. 
As  they  are  due  to  contractions  of  the  uterus,  which  tend  to  empty 


150 


THE    PUERPEKAL    STATE 


that  organ  and  also  to  bring  about  involution,  they  are  really  bene- 
ficial. On  this  account  we  should  avoid  interference  for  a  time. 
After  three  or  four  hours,  however,  it  is  well  to  give  some  simple 
opiate  if  the  pains  are  severe. 

Pulse. — The  pulse  usually  increases  in  frequency  during  labor, 
reaching  90  or  100,  but  shortly  after   delivery  it  becomes  less 


Fig.  98. — Bladder  after  Labor,  Empty,  Uterus  in  Normal  Position. 


rapid,  sinking  frequently,  if  not  generally,  below  the  normal  in 
from  eight  to  twenty-four  hours.  It  frequently  falls  to  50  and 
sometimes  to  40.  This  slowing  of  the  pulse  is  a  favorable  indi- 
cation and  generally  lasts  about  five  or  six  days. 

Temperature. — There  is  generally  some  increase  of  temperature 
during  labor,  which  may  continue  for  about  twelve  hours  after. 
Mcllwraith  believes  that  a  rise  of  temperature  during  labor  ought 
not  to  be  considered  physiological,  but  pathological,  inasmuch  as 
it  indicates  that  the  patient  is  growing  weak,  and  probably  re- 
quires artificial  assistance.  Generally,  however,  the  temperature 
declines  again  within  twenty-four  hours  and  remains  stationary 
during  seven  or  eight  days  with  only  the  usual  morning  and  even- 
ing variations.     There  are  no  special  changes  in  respiration. 

Modifications  of  Secretions. — The  secretions,  especially  from 
the  skin  and  kidneys,  are  greatly  increased  for  a  time  after  labor. 
Soon  after  delivery  the  body  is  generally  covered  with  perspiration, 
especially  during  sleep.  This  hypersecretion  continues  for  about 
a  week.  The  quantity  of  urine  is  also  greatly  increased.  This 
frequently  helps  to  cause  a  condition  which  may  be  considered 


GENERAL    CONDITIONS 


151 


to  a  certain  extent  patholof^ical,  or,  at  least,  abnormal;  that  is, 
retention  of  urine.  This  retention  may  exist  with  a  certain  amount 
of  overflow.  An  inexperienced  practitioner  does  not  always 
appreciate  the  fact  that  the  Ijladder  may  become  enormously 
distended  within  a  very  short  time  after  labor,  especially  if  it  has 
not  been  thoroughly  emptied  chn-ing  labor.  It  is  well  to  have  in 
one's  mind  the  fact  that  an  abdominal  enlargement  appearing  after 
labor  is  generally  due  to  a  distended  bladder.  A  friend  of  mine 
has  frequently  told  me  that  he  felt  extremely  mortified  on  one 
occasion  something  like  thirty  years  ago,  when  he  called  in  Dr. 
W.  T.  Aikins  to  make  a  diagnosis  of  an  abdominal  enlargement 
about  twenty-four  hours  after  the  termination  of  labor.  The 
enlargement  in  that  case  was  found  to  be  due  to  retention  of  urine. 
This  condition  is  discussed  in  another  part  of  this  chapter  under 
''Micturition." 

The  Condition  of  the  Digestive  Organs. — One  can  easily  under- 
stand that,  on  account  of  the  great  increase  of  the  secretions  of  per- 
spiration and  urine,  considerable  thirst  is  apt  to  occur  during  such 


Fig.  99. — Bladder  after  Labor,  Distended,  Uterus  pushed  upward. 


hypersecretion.  The  appetite  for  the  first  two  or  three  days  is 
generally  lessened  and  the  bowels  are  apt  to  be  slightly  constipated. 
Lochia. — On  account  of  some  doubt  as  to  the  derivation  of  the 
term  lochia,  the  word  may  be  used  either  in  the  singular  or  in  the 
plural,  although  I  think  it  is  more  commonly  considered  a  plural 
word.  The  lochial  discharge  is  composed  of  red  blood  cells,  por- 
tions of  clots,  and  shreds  of  decidua  at  first,  and  is  called  lochia 


152  THE    PUERPERAL    STATE 

rubra.  It  gradually  becomes  pale  in  color  and  in  about  a  week 
after  labor,  contains  colored  serum,  epithelial  and  cylindrical  cells, 
leucocytes,  albumin,  chlorides,  etc.,  and  is  called  lochia  serosa. 
Finally  it  becomes  muco-purulent  and  is  then  called  lochia  alba. 
The  character  of  the  lochia  varies  greatly  in  different  women. 
After  becoming  colorless,  or  nearly  so,  it  frequently  becomes  red 
again  without  any  apparent  cause.  The  discharge  generally  lasts 
from  two  to  five  weeks. 

The  lochia  within  the  uterus  should  always  be  sterile.  Gener- 
ally the  discharge  is  sterile  even  in  the  vagina  for  a  day  or  two,  but 
after  two  or  three  days  numerous  microbes  are  found  in  it,  such 
as  streptococci,  staphylococci,  and  colon  bacilli.  These  probably 
originate  mostly  from  those  existing  in  an  inert  condition  in  the 
vagina  before  delivery,  while  some  probably  enter  from  without. 

Changes  in  the  Cervix  Uteri. — Immediately  after  birth  the  cer- 
vix is  lying  relaxed  and  soft  and  the  os  more  or  less  torn.  The 
internal  os  is  not  well  marked  and  the  lower  uterine  segment  and 
the  cervix  appear  like  a  long  tube  with  thin  walls.  The  contraction 
ring  very  quickly  approaches  the  internal  os  and  the  two  become 
blended  in  a  week,  or  perhaps  less.  The  internal  cervical  ring 
remains  relaxed  and  soft  so  that  one  or  two  fingers  may  be  passed 
through  it  up  to  about  the  end  of  the  second  week.  It  is  possible, 
therefore,  to  explore  the  uterus  with  the  fingers  during  the  first 
two  weeks  after  labor. 

The  Breasts. — A  fluid  called  colostrum  is  found  in  the  breast 
during  the  latter  part  of  pregnancy  and  immediately  after  labor. 
This  colostrum  is  not  really  a  secretion  from  the  gland  cells,  but 
rather  a  transudation  from  the  blood.  It  differs  in  many  respects 
from  milk.  It  is  yellowish- white  in  color,  richer  in  fat  and  sugar 
than  milk,  and  contains  albumin  instead  of  caseinogen.  Microscop- 
ically it  contains  fat  globules,  pavement  epithelium,  occasional 
milk  corpuscles,  and  large  round  glandular  cells. 

The  Establishment  of  the  Secretion  of  Milk. — The  breasts  soon 
become  congested  and  at  the  same  time  hard  and  tense.  The 
swollen  condition  thus  produced  causes  some  discomfort  or  pain. 
There  is  sometimes  slight  general  disturbance  of  the  system,  which, 
in  the  old  days,  v/as  called  milk  fever.  The  secretion  of  milk  gen- 
erally commences  on  the  second  or  third  day  after  labor  and  is 
fully  established  by  the  third  or  fourth  day,  generally  the  third 
in  multiparge  and  the  fourth  day  in  primiparse. 


THE    CARE    OF    THE    MOTHER  153 

The  mother's  milk  is  not  pure,  as  formerly  supposed,  but  gen- 
erally contains  many  stai)hylococci  and  sometimes  a  few  strep- 
tococci. It  is  supposed  tliat  these  microbes  have  found  their  way 
into  the  breast  through  the  channel  of  the  nipples,  but  it  is  under- 
stood that  they  do  not,  under  ordinary  circumstances,  injure 
either  the  mother  or  -child. 

THE  CARE   OF  THE  MOTHER 

The  Visits  of  the  Physician. — The  physician  should  remain  in 
the  house  one  hour  at  least  after  the  expulsion  of  the  placenta. 
He  should  make  arrangements  to  have  the  patient  kept  as 
comfortable  as  possible  and  should  leave  some  rules  respect- 
ing the  treatment  of  the  after-pains.  He  should  also  leave 
instructions  to  keep  the  patient  as  quiet  as  possible  for  a  number 
of  hours. 

He  should  make  his  first  visit  within  twelve  hours  after  labor. 
He  should  at  this  time  get  full  information  as  to  temperature,  pulse, 
respiration,  time  occupied  in  sleep,  character  of  the  discharges, 
presence  of  pain  or  aches,  and  particularly  as  to  the  passage  of 
urine.  It  is  very  important  to  get  full  information  as  to  every 
symptom,  no  matter  how  slight  it  may  seem.  If  the  patient  has 
had  a  comfortable  time — if,  for  instance,  she  has  slept  a  good  por- 
tion of  the  night,  has  no  headache  or  any  other  unpleasant  symp- 
tom— one  has  great  reason  to  feel  encouraged.  If  she  says  that  she 
feels  very  well  excepting  that  she  has  a  slight  headache  and  did  not 
sleep  very  well,  there  is  reason  to  fear  that  something  is  wrong. 
The  first  visit  after  labor  should  never  he  a  hurried  one. 

While  asking  certain  questions  the  physician  should  watch  the 
patient  carefully  without  appearing  to  do  so.  He  should  note  the 
expression  of  her  face,  the  condition  of  her  eyes,  forehead,  lips,  etc., 
the  character  of  her  respirations,  the  position  in  which  she  is  lying, 
the  position  of  the  legs,  arms,  etc. 

After  the  first  day  the  physician  should  see  his  patient  at  least 
once  a  day  for  a  week  or  ten  days,  then  every  second  or  third  day 
until  the  end  of  the  third  or  fourth  week.  Such  directions  apply 
especially  to  attendance  on  patients  in  cities  or  towns.  It  happens 
in  many  country  districts,  that  the  physician  in  certain  cases 
makes  no  subsequent  visits  after  attending  his  patient  in  confine- 
ment-    I  do  not  think,  however,  that  any  physician  should  take 


154  THE    PUEKPERAL    STATE 

the  responsibility  of  conducting  a  case  of  labor  without  seeing  his 
patient  at  least  once  or  twice  after  the  birth  of  the  child. 

The  Duties  of  the  Nurse. — The  nurse  should  be  scrupulously 
clean  in  her  methods  and  should  be  careful  to  keep  the  patient  and 
everything  around  her  as  clean  as  possible.  The  vulvar  pads 
should  be  changed  frequently  and  the  parts  washed  with  a  warm 
aseptic  or  antiseptic  solution,  as  mentioned  in  connection  with  the 
management  of  labor.  The  antiseptic  solutions  are  preferred,  not 
so  much  on  account  of  any  inherent  virtue  existing  in  them,  but 
chiefly  because  their  systematic  use  for  external  washings  is  apt  to 
make  the  nurse  more  thorough  in  her  methods.  The  first  vulvar 
pad  should  be  removed  in  less  than  an  hour  after  its  application. 
After  the  second  pad  is  applied  the  nurse  should  generally  expect 
the  patient  to  have  some  rest.  With  that  object  in  view  she  should 
disturb  the  mother  as  little  as  possible.  A  sleep  of  an  hour  or  two 
at  this  time  is  worth  much.  When  she  wakens  the  nurse  should 
then  again  change  the  pad. 

There  was  at  one  time  a  belief  that  combing  or  brushing  the 
hair  was  apt  to  induce  post-partum  haemorrhage  during  the  first 
week  of  the  puerperium.  There  is,  of  course,  no  reason  for  such 
belief  excepting  in  so  far  as  the  dressing  of  the  hair  might  cause 
fatigue.  The  nurse  in  the  Burnside,  in  preparing  the  patient  for 
labor,  always  thoroughly  combs  and  braids  her  hair  after  she  has 
had  her  bath.  When  this  has  been  done  it  is  quite  a  simple  matter 
to  look  after  the  dressing  of  the  hair.  The  nurse  should  wash  the 
hands  and  face  at  least  twice  daily  and  should  also  sponge  the 
whole  body  with  tepid  water  once  a  day.  It  is  well  also,  especially 
in  warm  weather,  to  dust  with  baby  powder  such  regions  as  the 
groins  and  axillae. 

The  nurse  should  loosen  the  bandage  once  every  day  and  search 
for  the  fundus  uteri  so  that  she  may  properly  mark  the  involution 
line.  The  bandage  should  then  be  reapplied  as  carefully  as  it  was 
immediately  after  labor. 

Post-Partum  Vaginal  Douching. — Routine  vaginal  douching 
during  the  puerperium  was  very  commonly  carried  out  some  years 
ago.  I  have  for  a  long  time  opposed  the  practise  for  the  following 
reasons : 

1.  Douching  disturbs  that  perfect  rest  and  quiet  which  are  so 
desirable  for  a  patient  after  labor.  No  reference  is  here  made  to 
surgical  rest  of  wounded  tissues^  but  to  rest  in  a  general  way,  which 


THE    CAKE    OF    THE    MOTHER  155 

is  so  delicious  to  a  weary  and  more  or  less  exhausted  woman.  I 
have  often  thou<2;ht  and  sometimes  stated  that  meddlesome  mid- 
wifery reached  the  acme  of  absurdity  when,  in  1883,  T.  (laillard 
Thomas,  one  of  the  most  distinguished  oyna^eologists  in  the  world, 
recommended  one  of  the  most  extraordinary  methods  of  aggressive 
obstetrical  meddling- that  had  ever  been  conceived  by  the  brain 
of  man.  He  advised,  among  other  things,  the  administration  of 
a  douche  every  eight  hours  and  the  introduction  of  an  iodoform 
suppository  every  two  or  three  hours  for  at  least  ten  days  after 
delivery;  that  is  to  say — the  bruised  and  lacerated  vagina  was 
invaded  from  eleven  to  fifteen  times  every  twenty-four  hours  for  at 
least  ten  days,  if  the  unfortunate  victim  should  live  so  long.  Little 
wonder  was  it  that  Fordyce  Barker  entered  a  vigorous  protest. 

2.  Douching  is  unscientific  on  surgical  grounds.  After  labor 
the  utero-vaginal  canal  is  bruised  and  wounded.  On  surgical 
principles  the  most  important  points  in  the  treatment  are  rest, 
pressure,  position,  and  drainage.-  By  rest,  I  refer  to  that  physiolog- 
ical rest  to  which  so  much  importance  has  been  attached  by  Hilton 
and  many  others.  The  wounds  of  the  cervix  and  vagina  are,  as  a 
rule,  kept  closed  by  the  elastic  and  even  pressure  of  the  surrounding 
tissues.  The  introduction  of  suppositories  and  douching  seriously 
interfere  with  the  rest  and  pressure  as  described,  and,  in  my  opinion, 
materially  delay  healing  of  these  wounds.  The  recumbent  posture 
with  the  slight  changes  in  position  required  in  voiding  urine  and 
faeces  is  well  adapted  for  drainage. 

3.  Douching  is  actually  dangerous.  It  is  apt  to  disturb  clots 
and  thus  open  avenues  for  infection,  to  open  lacerations  of  the  cer- 
vix and  vagina  and  thus  prevent  them  from  healing,  to  wash  bac- 
teria into  the  uterine  cavity  and  thus  cause  septic  endometritis. 
Among  other  dangers  which  are  generally  clue  to  accident  or  care- 
lessness are  the  introduction  of  septic  matter  by  fingers  and  instru- 
ments. 

In  a  certain  minority  of  cases  the  douching  becomes  advisable, 
as  explained  in  the  chapter  on  Septicaemia. 

Care  of  Breasts. — Thirty  years  ago  obstetricians  were  taught 
to  be  careful  about  massage  of  the  breasts,  but  they  thought  a 
certain  amount  of  massage  and  pumping  was  necessary  in  some 
cases.  In  1882  Garrigues  commenced  the  systematic  use  of  his 
breast  bandage,  which  made  the  rubbing  and  pumping  unnecessary 
as  a  rule. 


156  THE    PUEEPEKAL    STATE 

Unfortunately,  a  serious  massage  epidemic  seems  to  be  spread- 
ing again  over  the  North  American  continent.  The  rubbing  and 
squeezing  evil  is  back  again  among  us.  I  think  that  four  artistic 
plates,  which  are  found  in  a  certain  Textbook  of  Obstetrics,  to- 
gether with  an  elaborate  description  of  the  technique  of  breast 


Fig.  100. — On  left,  piece  of  factory  cotton  36  x  16  in.  folded  twice  with  lines  indi- 
cating portions  to  be  cut  out.  In  center,  piece  of  cotton  with  portions  cut  out 
On  right,  piece  of  cotton  unfolded  showing  the  bandage  ready  for  application. 

massage,  is,  to  a  large  extent,  responsible  for  the  present  popularity 
of  this  dangerous  procedure.  According  to  Bacon,  of  Chicago,  the 
directions  seem  to  have  become  common  property  and  are  copied 
from  one  textbook  to  another  in  the  United  States. 

The  following  are  the  main  objects  of  the  breast-binder: 

1.  To  support  the  swollen  and  tender  breasts  when  congested 
and  distended  with  milk. 

2.  To  prevent  pain  by  evenly  applied  pressure,  which  prevents, 
to  some  extent,  the  congestion  and  distention. 

3.  To  ''dry  up"  the  breasts  when  the  child  is  still-born,  or 
when  the  patient,  through  disease  or  other  cause,  is  prevented 
from  nursing  her  babe. 

4.  To  prevent  mastitis. 

I  have  used  for  the  last  fifteen  years  a  breast-binder  devised  for 
me  by  Miss  Snively,  of  Toronto.  It  is  similar  in  shape  to  that  of 
Miss  Murphy  or  Dr.  Garrigues,  of  New  York. 

With  a  piece  of  cotton  and  a  pair  of  scissors  one  can  quickly 
cut  out  an  excellent  bandage.  The  following  directions  furnished 
by  Miss  Snively,  explain  very  clearly  how  it  is  made. 

Material,  16  to  18  inches  of  strong  factory  or  bleached  cotton, 
one  yard  wide. 


TTTE    OAUK    OF    THE    ^[O^rTTET? 


157 


1.  Fold  the  selvage  edges  together,  then  fold  in  the  same  direc- 
tion again.  The  cloth  is  now  four  thicknesses  and  must  remain  so 
until  all  cutting  is  finished. 

2.  Tiie  first  cut  will  he  on  the  side  opposite  the  selvage  edges. 
Place  scissors  2  implies  from  tlu^  edg{>  and  cut  downward  8  inches, 
taking  a  circular  direction  outward  after  cutting  7  inches.  This 
forms  the  armhole. 

The  straight  edge,  36  inches  long,  is  now  the  ])ottom  and  the 
opposite  side  the  top. 

3.  Now  fold  the  four  thicknesses  over  about  4  inches.  This 
will  bring  the  selvage  edge  even  with  the   first   7  inches  of  the 


_     wM 


Fig.  101.— Snively  Breast-Binder  applied. 


opening  first  made  for  the  arm.     Press  this  firmly  with  the  hand  so 
as  to  leave  the  mark  of  the  fold,  then  unfold. 

4.  Place  the  scissors  three  inches  from  the  top  on  the  selvage 
side  and  cut  in  a  circular  direction  toward  the  top  of  the  mark  of 
the  fold ;  this  forms  the  neck. 

5.  In  applying  binder  the  shoulder  pieces  can  be  joined  with 
small  safety-pins,  while  the  front  is  joined  with  ordinary  pins  or 
larger  safety-pins.  The  front  is  turned  in  to  fit  the  patient,  no 
sewing  being  required. 

Sometimes  the  bust  measures  more  than  36  inches;  in  such 


158  THE    PUEEPEEAL    STATE 

cases  take  a  piece  of  cotton  and  cut  it  lengthwise,  making  it  38 
or  40  inches  long  and  16  to  18  inches  wide.  Then  cut  as  directed 
in  rules  1,  2,  and  3. 

In  private  practise  I  use  the  Snively  bandage  in  all  cases  where 
the  breasts  become  in  the  slightest  degree  uncomfortable  from 
distention.  It  affords  a  wondrous  degree  of  comfort  in  a  large 
proportion  of  cases,  especially  in  "drying  up"  the  breasts.  No 
application  of  atropine  or  belladonna  is  required  when  the  bandage 
is  used. 

The  bandage  has  one  drawback  which  should  ever  be  kept  in 
view  in  the  nursing  woman.  It  diminishes  the  secretion  of  milk 
when  tightly  applied.     In  consequence  of  this  we  do  not  use  it  in 


Fig.  102. — Murphy  Binder,  "  Ready-made." 

all  cases  as  Garrigues  and  others  do  in  New  York,  but  only  when  the 
breasts  become  tender.  We  only  make  it  sufficiently  tight  to  re- 
lieve pain  and  remove  it  as  soon  as  we  can. 

Further  reference  is  made  to  this  bandage  in  speaking  of  the 
prevention  and  treatment  of  mastitis. 

Nipples. — In  speaking  of  the  hygiene  of  pregnancy,  it  was  stated 
that  it  is  dangerous  to  handle  the  nipples  to  any  great  extent.  The 
condition  of  the  nipples,  however,  should  be  ascertained  soon  after 
labor,  if  not  known  before.  It  is  sometimes  advisable,  especially 
in  primiparse,  to  make  certain  attempts  to  increase  the  prominence 
of  the  nipples  before  the  secretion  of  milk.  A  common  way  of 
doing  this  is  to  have  the  patient  herself  or  the  nurse  pull  the  nipples 
forward  with  the  fingers  in  imitation  of  the  action  of  the  babe's 
mouth.  Sometimes  they  may  be  drawn  out  by  gentle  suction  of 
a  breast  pump.  A  very  simple  and  common  method  of  suction  is 
by  means  of  a  hot  bottle.  Take  a  six  or  eight  ounce  bottle  and  fill 
it  with  hot  water,  pour  out  the  hot  water  rapidly  and  apply  the 


THE    CARE    OF    THE    MOTHER  159 

bottle  quickly  over  the  nipple.  The  condensation  of  the  air  which 
occurs  during  the  cooling  of  the  bottle  creates  a  partial  vacuum  and 
thus  a  certain  amount  of  suction  upon  the  nipple,  which  is  drawn 
into  the  neck  of  the  bottle.  Any  or  all  of  these  procedures  may, 
however,  seriously  irritate  and  injure  the  nipples. 

Food. — The  patient  is  not  generally  hungry  during  labor,  nor 
for  two  or  three  days  after,  as  before  mentioned.  It  is  not  neces- 
sary to  make  any  hard  and  fast  rule  as  to  diet,  but  to  be  largely 
guided  by  the  appetite  of  the  patient.  On  the  first  day  a  very 
simple  and  plain  diet  seems  most  suitable ;  for  instance,  hot  drinks, 
such  as  tea,  milk,  gruel  and  some  simple  solids,  such  as  bread  and 
butter,  bread  or  rice  puddings,  and  the  like.  On  the  second  day 
the  patient  may  take  any  sort  of  plain  sul^stantial  food  that  she 
chooses — that  is,  she  may  be  placed  on  what  we  call  mixed  diet. 
It  is  well,  however,  to  watch  the  effects  of  vegetables,  fruits,  and 
sweets  until  the  patient  has  left  her  bed  and  is  having  a  certain 
amount  of  exercise. 

Micturition. — As  before  mentioned,  there  is  likely  to  be  an  un- 
usually large  secretion  of  urine  for  sonle  days  after  labor.  For 
certain  reasons,  already  alluded  to,  retention  of  urine  is  not  unusual. 
The  nurse  should  look  after  the  patient  in  this  respect  and  encour- 
age her  to  void  urine  before  the  bladder  becomes  distended.  It  is 
frequently  difficult  for  the  patient  to  do  this  while  lying  on  her  back. 
If  not  too  much  exhausted  after  the  labor  it  is  well  sometimes  to 
raise  her  nearly,  if  not  quite,  to  the  sitting  position  or  allow  her  to 
turn  on  her  hands  and  knees.  Catheterization  should  be  avoided 
if  possible.  It  exposes  the  patient  to  the  risk  of  septic  infection 
of  the  bladder,  which  is  a  very  serious  condition.  Again,  when 
catheterization  has  been  once  performed  it  must  generally  be  con- 
tinued for  many  days.  One  should  remember,  however,  that 
retention  of  urine,  even  when  there  is  some  intermittent  or  con- 
tinuous flow,  not  infrequently  causes  enlarged  bladder  and  dis- 
placement of  the  uterus.  In  such  a  case  catheterization  is  neces- 
sary. Since  we  adopted  the  involution  line  w^e  have  discovered 
that  partial  retention  of  urine  is  more  common  than  we  formerly 
supposed,  and  is  the  cause  of  pain  in  the  region  of  the  uterus,  which 
may  last  for  days  and  is  frequently  misunderstood. 

One  of  the  most  common  expedients  for  encouraging  the  flow  of 

urine  is  to  place  a  hot  compress,  such  as  a  hot  sponge,  over  the 

suprapubic  region.     Miss  McKellar.  in  the  Burnside,  has  frequently 
13 


160  THE    PUERPERAL    STATE 

found  a  good  result  from  the  administration  of  an  enema.  The 
enema  of  soap  suds  is  retained  for  some  time,  the  patient  put  in  a 
partial  or  completely  sitting  position,  and  the  urine  is  voided  while 
the  soap  suds  or  fsecal  matter  is  coming  away  from  the  bowel. 

Bowels. — It  was  formerly  understood  that  the  bowels  should 
be  moved  on  the  third  day.  I  think  that  only  one  day  should  inter- 
vene before  the  bowels  have  been  moved.  For  instance,  when  a 
patient  in  labor  one  day  passes  the  following  day  without  a  motion 
of  the  bowels  an  aperient  should  be  given  that  same  evening.  It 
is  well  to  ascertain  what  cathartic  the  patient  is  in  the  habit  of 
taking.  Any  of  the  simple  cathartics,  such  as  rhubarb  pills,  cas- 
cara,  compound  licorice  powder,  phosphate  of  soda,  sulphate  of 
soda,  etc.,  will  answer  very  well.  After  taking  the  cathartic  in  the 
evening  an  enema  may  be  administered  the  following  day  before 
noon,  if  necessary. 

The  patient  should  be  kept  in  bed  nine  to  fourteen  days  after 
labor. 

She  may  be  allowed  to  walk  in  three  weeks. 

She  should  be  well  in  four  weeks,  but  should  not  do  much  work 
for  six  weeks. 

THE  CONDITION  AND  CARE  OF  THE  BABE 

The  following  are  a  few  of  the  practical  points  in  connection 
with  the  anatomy  and  physiology  of  the  babe : 

Breathing. — The  breathing  is  superficial,  and  rapid  up  to  50  a 
minute;  the  pulse  can  not  be  counted  at  the  wrist  immediately  after 
birth,  but  can  be  over  the  heart.  The  rate  is  130  to  140  during  the 
first  two  months,  120  to  130  from  the  third  to  the  sixth  month,  115 
to  120  from  the  seventh  to  the  twentieth  month. 

Evacuations  from  the  Bowels. — Some  meconium  may  be  ex- 
pelled during  the  birth  of  the  child  and  more  is  expelled  shortly 
after  birth.  It  is  a  dark,  green,  tarry  substance.  This  is  followed 
by  brown  fsecal  matter,  which  becomes  lighter  in  color  until  the 
end  of  the  first  week,  when  it  has  a  light  yellow  color. 

Urine. — There  is  very  little  urine  in  the  bladder  at  birth  and 
very  little  is  secreted  during  the  first  twenty-four  to  thirty-six 
hours.  When  urination  takes  place  very  soon  after  birth  the  fluid 
is  light  in  color,  but  when  delayed  for  twenty-four  to  thirty-six 
hours  it  is  apt  to  have  a  deep  yellow  color  and  to  be  turbid.  Some- 


CONDITIOX    AXl)    CARE    OF    THE    BABE         IGl 

times  it  contains  considerable  uric  acid  and  urates  causing  yellow- 
ish or  red  deposits  on  the  napkin,  which  are  sometimes  mistaken 
for  l)l()od.  No  alarm  need  be  caused  if  the  urine  is  not  voided 
inside  of  thirty  hours.  If  no  urine  is  passed  within  thirty-six  to 
forty  hours  it  is  better  to  pass  a  small  catheter  or  a  silver  probe ; 
but  this  is  very  rarely  necessary. 

Bladder. — The  bladder,  when  distended,  is  egg-shaped  and  lies 
chiefly  in  the  abdomen.  The  muscular  wall  is  relatively  thick, 
causing  the  bladder  in  female  infants  sometimes  to  be  mistaken  for 
the  uterus  on  post-mortem  examination.  The  urethra  is  situated 
along  the  anterior  wall  of  the  vagina  and  its  meatus  appears  almost 
as  large  as  the  orifice  of  the  vagina.  This  causes  a  little  confusion 
sometimes  in  passing  a  catheter. 

Growth. — The  average  weight  at  birth  is  7  pounds  (3,200  gm.), 
the  average  length,  20  inches  (50  cm.).  The  babe  loses  weight  for 
two  or  three  days  after  birth,  but  after  the  fourth  or  fifth  day 
it  should  commence  to  grow  and  such  growth  should  continue 
steadily. 

The  Cord. — After  the  first  dressing  the  cord  requires  no  special 
care.  If  the  dressing  is  disturbed  by  the  daily  bath  it  may  be  re- 
placed in  a  clean  way.  The  cord  generally  separates  in  from  four 
to  eight  days,  a  small  superficial  ulcer  being  left.  This  should  be 
kept  clean  and  dry  and  dusted  with  boric  acid. 

The  diapers  should  be  changed  frequently.  When  soiled  the 
buttocks  and  genitals  should  be  washed  with  lukewarm  water,  but 
after  washing  the  parts  should  not  be  wiped  with  an  ordinary  towel. 
Soft  linen,  cotton  or  muslin  should  be  gently  pressed  against  the 
skin  so  as  to  soak  up  the  moisture,  the  parts  should  then  be  dusted 
with  some  fine  powder,  such  as  talcum. 

The  Stomach. — The  stomach  of  a  new-born  babe  is  very  small, 
being  little  more  than  a  simple  dilatation  of  the  intestinal  tube,  and 
will  hold,  without  distention,  little  more  than  an  ounce  of  fluid. 
When  more  than  an  ounce  is  taken  vomiting  is  apt  to  occur  from 
simple  contraction  of  the  stomach  walls.  This  occurs  very  fre- 
quently and  should  cause  no  alarm,  as  it  is  not  ordinary  vomiting 
but  a  simple  regurgitation  without  nausea. 

Feeding. — During  the  first  three  days  before  the  secretion  of 
milk  in  the  mother's  breast  the  babe  requires  very  little  or  no  food. 
A  little  plain  warm  water  slightly  sweetened  may  be  given  to  it 
occasionally  during  these  early  days.     Generally  speaking,  during 


162  THE   PUERPERAL   STATE 

the  first  month  the  child  takes  about  20  ounces  daily,  during  the 
second  about  24  ounces,  during  the  third  about  28  ounces,  from 
the  fourth  to  the  ninth  month  30  to  35  ounces. 

It  is  generally  recognized  that  in  the  interests  of  the  child  the 
mother,  providing  there  be  no  contraindication,  should  always 
nurse  her  babe.  In  some  respects  this  is  also  in  the  interests  of 
the  mother,  because  involution  of  the  pelvic  structures  takes  place 
more  slowly  when  the  mother  does  not  nurse  her  babe. 

Contraindications  to  Maternal  Nursing. — It  is  not  easy  to  lay 
down  definite  rules  as  to  such  contraindications.  On  the  one  hand 
the  healthy  woman  should  always  nurse  her  babe,  unless  her 
nipples  are  extremely  deformed ;  on  the  other  hand,  a  woman  suf- 
fering from  advanced  tuberculosis,  severe  puerperal  septicaemia, 
or  any  disease  which  greatly  enfeebles  the  system,  should  not 
attempt  to  nurse  her  child.  Generally  speaking  it  would  be  neither 
in  the  interests  of  her  child  nor  herself. 

In  cases  of  doubt,  however,  it  is  well  for  the  mother  to  make 
the  effort  to  nurse  her  babe  in  part  at  least.  Frequently  she  may 
be  able  to  nurse  the  babe  wholly  or  partly  for  three  or  four  months, 
but  if  it  becomes  evident  at  any  time  that  such  efforts  are  injuring 
the  mother,  and  perhaps  the  babe  as  well,  the  suckling  must  be 
stopped  entirely. 

The  mother  may  not  have  sufficient  milk  for  her  child  even  at 
any  one  time  of  nursing.  When  in  doubt  on  this  point  it  is  always 
well  to  offer  the  babe  a  little  sweetened  warm  water  after  suckling. 
Always  take  care  that  the  babe  has  sufficient  liquid.  Never  let  a 
day  pass  without  the  mother  or  nurse  offering  the  child  three  or 
more  times  in  the  day  a  certain  amount  of  sweetened  water. 

Wet  Nurse. — Next  to  the  mother,  probably  all  will  agree  that 
a  suitable  wet  nurse  is  best  for  the  child.  It  is  a  very  simple  thing 
thus  to  state  what  may  be  considered  an  actual  truism,  but,  unfor- 
tunately, it  is  an  exceedingly  difficult  thing  to  get  a  suitable  wet 
nurse.  A  wet  nurse  should  be  perfectly  healthy  in  all  respects,  but, 
especially,  free  from  tuberculosis  or  syphilis.  Her  mammary 
glands  should  be  well  developed  and  the  nipples  should  be  well 
formed.  The  milk  should  contain  not  less  than  10  per  cent,  of 
cream.  It  is  better,  if  possible,  to  have  a  married  woman.  In  the 
majority  of  instances  a  wet  nurse  is  more  or  less  unsatisfactory,  and 
frequently  intolerably  so.  Artificial  feeding  is,  of  course,  not  satis- 
factory, but  on  an  average  it  is  probably  better  than  wet  nursing. 


CONDITION    AND    CAllE    OF    THE    BABE         163 


ARTIFICIAL  FEEDING 

Milk. — All  things  considered,  cow's  milk,  when  properly  modi- 
fied, makes  the  best  food  we  can  get  for  infants.  It  contains,  how- 
ever, more  caseinogen  and  less  sugar  than  woman's  milk.  It 
should,  therefore,  be  diluted  so  as  to  diminish  the  proportion 
of  casein  and  should  be  sweetened  with  cane  sugar  or  sugar 
of  milk.  Some  think  that  it  should  be  completely  or  partially 
sterilized. 

Sterilization.  To  sterilize  milk  thoroughly  so  as  to  destroy  the 
bacteria  and  spores  of  bacteria  it  is  necessary  to  boil  the  milk  not 
less  than  thirty  minutes.  This  decomposes  the  sugar,  melts  the 
fat,  and  toughens  the  casein  in  a  way  that  renders  it  much  less 
digestible  than  the  unsterilized  milk. 

Pasteurization.  This  means  a  partial  sterilization  of  the  milk 
at  a  temperature  not  exceeding  158°  F.  for  fifteen  minutes. 
This  is  said  to  destroy  the  typhoid,  diphtheria,  and  tubercle  bacilli 
and  also  a  large  proportion  of  bacteria.  The  process  probably 
injures  the  digestibility  somewhat,  but  not  nearly  so  much  as  the 
complete  sterilization. 

The  following  are  simple  rules  as  to  the  methods  of  modifying 
cow's  milk  for  infants. 

During  the  first  month  mix  the  cow's  milk  with  twice  the  quan- 
tity of  plain  water  and  add  one-half  teaspoonful  of  milk  sugar  for 
each  feeding.  During  the  second  month  mix  the  milk  and  water 
in  equal  parts  and  add  milk  sugar  as  before.  During  the  third  and 
fourth  months  mix  two-thirds  to  three-fourths  of  milk  with  one- 
third  to  one-fourth  of  water.  During  fifth  and  sixth  months  give 
the  milk  undiluted.  Some  prefer  to  dilute  the  milk  by  mixing  it 
with  barley  water  instead  of  plain  water.  It  is  probably  not  well, 
however,  to  use  the  barley  water  before  the  third  month  on  account 
of  the  starch  which  it  contains. 

Cream  Mixtures. — The  cream  mixtures,  of  which  there  are  many 
varieties,  are  probably  the  best  for  infant  feeding.  Skim  the  cream 
from  milk  after  it  has  been  standing  six  or  eight  hours,  or,  say,  over- 
night. Some  prefer  to  leave  the  milk  standing  in  a  jar  for  some 
hours  and  then  siphon  off  the  lower  half,  two-thirds,  or  three- 
quarters  of  the  milk  thus  leaving  the  portion  which  contains  the 
cream.     One  can  not  lay  down  any  fixed  rules  as  to  the  proportion 


164 


THE    PUEEPEEAL    STATE 


of  a  cream  mixture  which  will  suit  all  infants,  but  the  following 
table,  by  Louis  Starr,  may  be  taken  as  an  excellent  guide : 

Table  of  Ingredients,  Hours  and  Intervals  of  Feeding,  and  Total 

Quantity  of  Food  for  a  Healthy  Artificially- fed  Infant 

from  Birth  to  the  End  of  the  Seventh  Month. 


Age. 


During  1st 
week .... 


From  2d  to 
6th  week . 


fsij 


f3ij 


From  6th 

week  torr- 
end  of  2d  ^  ">  ^^ 
month .  .  . 


From  3d  to 
6th  month 


During  6th 
and  7th 
months .  . 


flss 


f  I  ss 


f3iij 


f?ss 


f3x 


f!ij 


f  1  iijss 


gr.xx 


gr.xx  a  pinch 


3  ss 


3j 


a  pinch 


a  pinch 


3  j     a  pinch 


I  3  iij 


n] 


fSx 


ffife 


5  A.M.  to 
11  P.M. 


5  A.M.  to 
11  P.M. 


5  A.M.  to 
11  P.M. 


flisS   5  A.M.  to 


f!ij 


7  A.M.  to 
10  P.M. 


2  hours 


2  hours 


2  hours 


24  hours. 


3  hours 


O  3 
HO" 


f!xij 


f  !xvij 


f  ?  XXX 


f  §  xxxij 


f  I  xxxvj 


It  is  more  convenient  to  vary  the  ingredients  of  the  cream  mix- 
ture according  to  the  age  of  the  child.  Some  prefer,  however,  to 
determine  the  composition  and  amount  of  food  according  to  the 
weight  instead  of  the  age.  It  is  perhaps  better  to  consider  both 
the  weight  and  age.  For  instance,  one  babe  at  six  months  may 
not  be  larger  than  another  at  three  months.  In  such  a  case  it  is 
better  to  give  the  food  suitable  for  the  earher  age.  It  is  generally 
better  in  all  cases  to  dilute  the  food  rather  than  change  it  when  the 
child  is  not  thriving.  The  mothers  can  not  always  understand 
the  philosophy  of  such  treatment,  but  it  is  better  to  teach  them 
if  possible. 

One  of  the  most  important  columns  of  the  Starr  table  is  that 
which  gives  the  intervals  of  feeding.  The  infant  should  be  fed  with 
absolute  regularity  whether  it  gets  mother's  milk  or  artificial  food. 
The  young  babe  should  have  one  long  sleep  of  six  hours  during  the 
night,  and  should  be  wakened  at  the  proper  hours  during  the  day — 
i.  e.,  every  two  hours  if  necessary.  Many  mothers  and  nurses  dis- 
like to  disturb  peaceful  sleep,  but  there  is  no  harm  in  doing  so. 


CONDITION"    AiYD    CAEE    OF    THE    BABE  165 

The  babe  will  take  its  meal  after  being  thus  disturbed  and  go  back 
to  the  "peaceful  sleep"  in  good  time,  often  immediately.  It 
should  sleep  eighteen  to  twenty  hours  out  of  twenty-four,  but  if 
allowed  to  sleep  four  or  five  hours  at  one  time  during  the  day  it  is 
more  apt  to  become  wakeful  at  night.  Good  or  bad  training  in 
such  regard  will  produce  in  young  infants  good  or  bad  habits  in  a 
very  short  time. 

It  is  better  in  some  cases  to  use  the  whey  for  a  longer  time  than 
one  week  as  recommended  by  Starr.  Whey  and  cream  form  an 
admirable  mixture. 

Vigier's  method  of  preparing  cream  and  whey  mixture : 

Divide  one  quart  of  milk  into  equal  portions,  let  both  stand 
three  or  four  hours  in  a  cool  place.  Then  skim  the  cream  from  one 
portion  and  add  it  to  the  other.  Add  one  teaspoonful  of  liquid 
rennet  to  the  skimmed  portion  and  warm  to  95°  to  104°  F.  with 
frequent  stirring  for  twenty  minutes,  or  until  it  forms  a  tough 
curd.  Then  heat  to  a  temperature  of  155°,  after  which  strain 
through  muslin  and  cool.  For  infants  under  five  months  mix 
equal  volumes  of  this  whey  with  the  enriched  milk.  I  prefer  for 
infants  under  two  months  mixing  two-thirds  of  whey  with  one- 
third  of  rich  milk.  With  infants  over  six  months  mix  two  parts  of 
rich  milk  with  one  of  whey. 

Monti  prefers  a  mixture  of  whey  with  ordinary  milk  in  equal 
volumes  for  the  first  three  months,  and  after  that  two  parts  of  milk 
with  one  of  whey.  When  a  child  appears  to  be  suffering  from  in- 
digestion, as  shown  by  the  presence  of  undigested  casein  in  the 
stools,  it  is  well  to  feed  the  babe  for  one,  two,  or  three  days  on  whey 
alone.  Even  when  depending  on  whey  alone  or  any  mixture  of 
whey  with  cream  or  milk,  it  is  still  desirable  to  offer  the  babe  fre- 
quently plain  water  or  plain  sweetened  water  to  drink. 

One  should  be  very  careful  to  see  that  the  bottles  and  nipples 
are  properly  cared  for.  Each  bottle  should,  if  possible,  be  only 
sufficiently  large  to  contain  about  one  meal  for  the  babe.  The  nip- 
ples should  be  made  of  plain  black  rubber,  with  three  holes  of  size 
not  to  allow  too  much  nor  too  little  milk  to  pass.  When  too  much 
passes  it  chokes  the  child,  and  when  too  little  can  be  drawn  through 
the  child  grows  tired  of  sucking. 

While  the  infant  is  being  fed  it  should  lie  on  its  back  with  the 
head  a  little  raised.  The  bottle  should  be  held  or  placed  so  that 
the  bottom  points  upward,  with  the  nipple  placed  against  the 


166  THE    PUERPEEAL    STATE 

tongue.  Garrigues  points  out  that  if  these  rules  are  observed  the 
child  is  not  apt  to  get  its  stomach  filled  with  air. 

Condensed  Milk. — Condensed  milk  is  used  by  many  for  infants 
up  to  the  ages  of  nine  to  twelve  months.  The  canned  milk,  which 
contains  a  large  amount  of  sugar,  is  more  commonly  used.  This 
milk,  in  addition  to  containing  too  much  sugar,  has  also  some 
of  the  disadvantages  of  sterile  milk,  and  should  not  be  used  for 
any  length  of  time.  I  believe,  however,  that  it  does  very  well 
for  a  limited  time,  up  to  three  months,  if  not  more.  Such  being  the 
case,  it  may  be  used  by  people  who  are  not  in  a  position  to  devote 
the  time  to  the  proper  preparation  of  other  food,  such  as  cream 
mixtures.  It  is  often  more  convenient  and  safer  for  young  chil- 
dren when  traveling. 

Manufactured  Artificial  Foods. — Some  of  the  artificial  foods  now 
found  in  the  market  are  very  good.  I  think  it  better  to  choose 
those  which  may  be  mixed  with  warm  water.  Such  foods  are  also 
convenient  and  safe  for  children  when  traveling. 

When  the  mother  is  able  to  nurse  her  child  she  should  do  so  for 
nine  months.  The  period  of  lactation  may  perhaps  be  prolonged 
to  twelve  months,  or  it  may  require  to  be  curtailed.  Very  fre- 
quently it  happens  that  the  child  may  get  its  nourishment  par- 
tially from  the  breast  and  require  supplementary  feeding  with 
artificial  foods. 

CARE   OF  PREMATURE   INFANTS 

We  can  not  say  exactly  at  what  period  of  time  in  pregnancy  a 
child  becomes  viable.  It  is  generally  supposed  that  the  child  is 
viable  at  the  end  of  the  seventh  month  of  gestation.  This  is  recog- 
nized by  law  in  certain  countries.  It  is  probably  a  fact  that  a 
child  may  be  viable  at  the  end  of  the  sixth  month.  From  a  medical 
standpoint  it  is  probably  better  to  consider  any  child  viable  when 
it  breathes  at  birth. 

It  is  well  at  the  same  time  to  have  a  clear  idea  of  the  general 
appearance  of  a  seventh-month  foetus.  A  singular  case  occurred 
a  few  years  ago,  in  which  Dr.  Temple  and  myself  were  called  to 
report  as  to  the  probable  viability  of  an  infant. 

A  premature  infant  expelled  at  2  a.m.  Supposed,  from  the 
history,  to  be  five  months  advanced.  Poor  light,  poor  surround- 
ings, in  a  small  house.  Foetus,  when  examined  with  the  dim  light 
of  the  candle,  showed  no  sign  of  life  and  was  left  on  the  bed  for 


CONDITION    AND    CARE    OF    THE    BABE  167 

some  time  while  the  mother  was  cared  for.  Fcetus  again  examined 
carefully,  covered  with  cotton-batting  and  placed  in  a  rough  box, 
which  was  covered,  and  carried,  between  9  and  10  a.  m.,  to  what 
would  correspond  to  a  vault  in  a  large  cemetery,  the  intention  being 
to  bury  it  in  an  hour  or  so.  Some  one  passing  thought  he  heard  a 
cry.  The  box  was  opened  and  the  infant  was  found  to  be  living. 
It  was  exceedingly  feeble,  however,  and  died  in  a  few  hours. 

In  our  report  we  expressed  the  opinion  that  the  child  was  born 
in  the  seventh  month  of  pregnancy  and  perhaps  early  in  that  month. 
While  the  child  was  born  alive,  we  doubted  whether  it  could  be  con- 
sidered viable  in  the  proper  sense  of  the  word — that  is,  we  doubted 
whether  it  was  born  with  sufficient  vigor  to  enable  it  under  the  best 
of  circumstances  to  live  to  manhood  or  even  to  boyhood. 

Two  things  are  of  great  importance  in  the  care  of  a  premature 
infant : 

1.  The  maintenance  of  the  body  temperature. 

2.  The  proper  administration  of  nourishment. 

The  Maintenance  of  the  Temperature  of  the  Body. — Heat  is  the 
all-important  thing  for  the  premature  babe.  Artificial  respiration, 
which  is  so  important  in  certain  cases  for  the  full-term  babe,  is  not 
of  much  use  for  the  premature  infant.  The  old-fashioned  way  of 
treating  the  premature  babe  was  to  wrap  it  up  warmly  and  put  it 
behind  the  kitchen  stove.  Such  procedure  seems  sometimes  to  be 
quite  as  effective  as  the  use  of  the  most  modern  and  expensive 
incubator. 

Incubator.  An  incubator  is  something  that  one  can  very  easily 
manufacture  in  any  house,  even  in  the  backwoods.  A  large  market- 
basket,  a  small  clothes-basket,  or  a  candle-box  is  used.  One-half 
the  basket  or  box  is  filled  with  cotton-wool  or  something  of  that 
sort.  The  child  is  anointed  thoroughly  with  warm  sweet-oil  or 
cod-liver  oil  (which  I  prefer),  and  placed  undressed  in  the  basket 
or  wooden  box  on  the  cotton-wool,  having,  however,  an  absorbent 
pad  under  the  buttocks  for  the  collection  of  faeces  and  urine.  Cot- 
ton-wool is  then  added  to  the  sides  and  over  the  front  of  the  child, 
leaving  only  the  face  and  part  of  the  head  uncovered.  Two  hot- 
water  bottles  are  placed  on  either  side  and  one  below  the  feet. 
The  hot-water  bottles  are  so  arranged  that  they  can  be  filled  with- 
out disturbing  the  child.  The  temperature  in  the  box  is  kept  at  or 
about  85°  to  95°  F.  and  the  temperature  in  the  room  from  72° 
to  75°,  or  perhaps  even  up  to  80°,  for  the  first  half  day.     The  box 


168  THE    PUEKPERAL    STATE 

may  be  covered  by  a  quilt  or  shawl,  leaving  the  face  still 
uncovered. 

The  only  difficulty  that  one  need  experience  in  a  house  in  the 
backwoods  will  perhaps  be  the  want  of  a  thermometer.  In  such  a 
case  put  in  the  bottles  water  as  hot  as  the  hand  may  be  immersed 
in  without  discomfort,  change  occasionally,  and  leave  the  box  in 
a  portion  of  some  warm  room  where  you  are  satisfied  the  tempera- 
ture is  not  below  70°. 

If  something  more  pretentious  in  the  way  of  an  incubator  is 
required  the  Tarnier  or  Crede  or  Auvard  or  ' '  Ideal ' '  incubator 
may  be  chosen. 

The  Proper  Administration  of  Nourishment. — The  premature 
infant,  like  any  other  infant,  should  receive  definite  amounts  of 
nourishment  at  regular  intervals,  the  quantity  and  frequency  of 
administration  depending  upon  its  age,  vigor,  etc.  The  mother's 
milk,  of  course,  is  the  best  food.  The  milk  from  a  healthy  wet- 
nurse  will  answer  if  milk  from  the  mother  is  not  available.  If 
artificial  feeding  becomes  necessary  some  of  the  foods  which  have 
been  recommended  should  be  used,  a  mixture  of  very  little  cream 
with  whey  and  a  little  lime-water  being  one  of  the  best.  During 
the  first  day  probably  plain  warm  water,  a  quarter  to  one-half  tea- 
spoonful  every  hour  or  two,  will  be  sufficient,  or  occasionally  the 
same  quantity  of  milk  from  the  mother's  breast,  or  artificial 
food.  It  is  generally  better  to  give  it  to  the  babe  with  a  tea- 
spoon, or  a  few  drops  may  be  introduced  into  the  back  part  of 
the  mouth  or  the  pharnyx  through  an  ordinary  medicine  dropper 
or  small  syringe. 

Gavage. — Another  method  of  administering  food  is  known  as 
gavage.  The  infant  hes  with  the  head  slightly  raised,  a  14  or  16 
(French)  soft  rubber  urethral  catheter,  thoroughly  sterilized,  is 
first  anointed  with  a  little  of  the  food  to  be  given.  It  is  then  in- 
troduced into  the  pharynx  and  gently  passed  on  to  the  stomach  as 
the  child  swallows.  A  little  artificial  food  is  passed  through  the 
catheter  from  a  small  glass  funnel  or  syringe  inserted  into  the 
outer  extremity  of  the  tube. 


CHAPTER    IX 

FACE   PRESENTATIONS,   BREECH  PRESENTATIONS, 
MULTIPLE   PREGNANCIES 

FACE  PRESENTATION 

This  condition  is  found  in  1  out  of  250  cases  and  is  probably 
produced  by  extension  of  the  occiput  in  vertex  presentations.  It 
is  thought  by  some  that  such  extension  is  occasionally  found  be- 
fore labor,  but  in  the  great  majority  of  cases  it  is  developed  after  the 
onset  of  labor.     The  causes  are  briefly  these : 

Obliquity  of  the  uterus,  through  which  the  head,  instead  of  being 
driven  downward  into  the  pelvis  is  forced  against  the  side  of  the 
brim.  In  this  way  the  descent  of  the  occiput  is  arrested  and  the 
descent  of  the  chin  is  favored.  Dolichocephalic  head — that  is,  with 
occiput  projecting,  causing  lengthening  of  the  posterior  arm  of  the 
cephalic  lever  (doubted  by  some).  Round  and  small  head,  causing 
equality  of  the  two  arms  of  the  cephalic  lever.  Flat  pelvis,  pre- 
venting the  broad  occipital  portion  from  engaging  in  contracted 
conjugate  diameter  and  causing  it  to  be  pushed  to  the  side  of  the 
pelvis.  Congenital  swellings  of  the  neck — tumors  of  the  thyroid  or 
thymus  glands.  Small  foetus.  Anencephalic  foetus.  Hydramnios, 
especially  with  sudden  escape  of  liquor  amnii.  Coiling  of  cord 
round  the  neck.  Occipito-posterior  positions  in  which  there  is  a 
"tight  fit"  at  the  brim  (Cameron  and  Webster). 

Among  these  causes  the  most  common  are  obliquity  of  the 
uterus,  especially  when  the  back  of  the  child  is  toward  the  mother's 
right  side,  flat  pelvis,  and  hydramnios.  It  is  especially  important 
to  keep  these  causes  in  view,  because  they  can  generally  be  dis- 
covered during  pregnancy. 

Diagnosis. — Abdominal  palpation.  Sometimes  diagnosis  by  pal- 
pation alone  is  exceedingly  difficult  or  impossible;  sometimes  the 
projecting  occiput  can  be  readily  detected  above  the  pubes  and 
at  one  side,  while  the  breech  is  felt  at  the  fundus  on  the  same  side 
(Pinard).     The  heart  sounds  can  generally  be  heard  on  the  opposite 

169 


170  FACE    AND    BREECH    PEESENTATIONS 

side  because  in  face  presentation  the  chest  of  the  foetus  usually 
presses  directly  against  the  uterine  wall,  while  the  back  does  not. 
We  therefore  hear  the  heart  sounds  from  the  front  of  the  chest 
instead  of  from  the  back.  The  furrow  between  the  back  and  occi- 
put may  sometimes  be  felt,  and  there  is  a  lack  of  adaptation  of  the 
foetus  to  the  uterus  and  abdomen. 

Digital  Examination.  As  the  presenting  part  is  high  up  early 
in  labor  it  is  difficult  to  make  out  much  by  a  vaginal  examination. 
The  examining  finger  may  touch  the  forehead  and  this  may  be 
mistaken  for  the  vertex.  After  a  time  we  are  able  to  feel  the  fore- 
head, the  edges  of  the  orbits,  eyes,  nose,  nostrils,  mouth  with  its 
hard  alveolar  ridges,  and  the  chin.  Sometimes,  however,  the  face 
is  swollen  and  distorted  to  such  an  extent  that  it  may  be  mistaken 
for  the  breech.  The  simplest  way  to  be  sure  of  the  diagnosis  is  to 
press  on  the  alveolar  ridges  inside  the  mouth.  These  correspond 
to  nothing  found  in  the  rectum,  where,  instead  of  hard  ridges,  we 
find  shght  action  of  the  sphincter,  which  caused  Parvin  to  make  use 
of  the  expression,  ' '  The  anus  bites  instead  of  the  mouth. ' '  In 
making  the  examination  it  is  always  important  to  note  the  direc- 
tion of  the  chin ;  the  best  guide  to  that  is  the  nostrils,  which  point 
in  the  direction  of  the  chin. 

Mechanism  of  Face  Presentations. — The  mechanism  of  vertex 
presentations  being  known,  it  is  a  simple  matter  to  get  a  clear  con- 
ception of  the  mechanism  of  face  presentations.  In  the  latter  the 
chin  plays  the  same  part  that  the  occiput  does  in  vertex  presenta- 
tions. As  the  head  descends  rotation  must  occur  in  the  one  case  as 
well  as  in  the  other.  In  vertex  cases,  under  normal  circumstances, 
the  vertex  is  the  lowest  part  of  the  head  in  the  pelvis ;  this  is  pro- 
duced by  flexion  of  the  head.  In  face  presentations  the  chin  is  the 
lowest  part  of  the  head  in  the  pelvis  and  this  is  due  not  to  flexion 
but  to  extension.  Extension  of  the  head  turns  the  occipito-left- 
anterior  into  the  right  mento-posterior  and  so  on,  thus  (Fothergill) : 

1.  O.  L.  A.  =  M.  R.  P.     Mentum  right  posterior. 

2.  O.  R.  A.  =  M.  L.  P.      Mentum  left  posterior. 

3.  O.  R.  P.  =  M.  L.  A.      Mentum  left  anterior. 

4.  O.  L.  P.  =  M.  R.  A.     Mentum  right  anterior. 
The  order  of  frequency  is :  1,  3,  2,  4. 

There  is  some  doubt  as  to  whether  the  first  or  third  face 
position,  that  is,  the  mentum  right   posterior  or  the  mentum 


FACE    PRESEXTATIOX  171 

left  anterior,  is  tlie  more  common,  but  all  are  agreed  that  these 
two  positions  arc  fur  more  common  than  the  others — that  is, 
in  these  presentations  the  face  nearly  always  lies  in  the  right 
oblique  diameter  the  chin  being  to  the  left  front  or  toward  the 
right  rear. 

The  mechanism  is  the  converse  of  that  in  vertex  cases. 

There  are  four  movements,  (mentum  right  posterior)  : 

1.  Extension  and  descent. 

2.  Internal  rotation — long  rotation  of  chin  to  front  through 
three-eighths  of  a  circle, 

3.  Flexion. 

4.  External  rotation. 

Very  rarely  we  have  a  malrotation  with  the  mechanism  as 
follows : 

1.  Imperfect  extension  or  slight  flexion  with  descent. 

2.  Internal  rotation — short  rotation  of  forehead  instead  of  chin 
to  front  through  one-eighth  of  a  circle. 

3.  Extension. 

4.  External  rotation. 

This  malrotation — i.  e.,  the  rotation  of  the  forehead,  brings  the 
chin  into  the  hollow  of  the  sacrum,  making  it  a  persistent  mento- 
posterior position,  in  which  natural  expulsion  is  nearly  always 
impossible. 

The  three  important  movements  in  the  delivery  of  normal  face 
presentations  are  descent  and  extension,  rotation  of  the  chin  to 
the  arch,  and  delivery  of  the  head  by  flexion.  The  fourth  move- 
ment of  external  rotation  which  is  generally  described  is  less 
important. 

The  mechanism  of  the  first  position  may  be  more  minutely  de- 
scribed as  follows :  When  labor  begins  the  forehead  is  lower  down 
than  the  chin,  during  descent  extension  takes  place  which  causes 
the  chin  to  come  lower  down;  next,  a  rotation  takes  place  which 
turns  the  chin  toward  the  pubic  arch.  The  rotation  of  the  chin 
is  brought  about  in  the  same  way  as  that  of  the  occiput  in  normal 
labors — that  is,  by  pressure  against  the  posterior  part  of  the  pelvic 
floor,  especially  the  strong  sciatic  ligaments.  The  right  cheek, 
which  is  anterior,  descends  a  little  lower  than  the  other,  the  mouth 
and  chin  appear  at  the  vulva.  As  soon  as  the  chin  gets  clear  of 
the  pubic  arch  flexion  occurs  by  which  the  chin  is  pushed  up  in 
front  of  the  symphysis  pubis,  while  the  nose,  eyes,  forehead  and 


172 


FACE    AFD    BEEECH    PEESENTATIONS 


vertex  successively  roll  over  the  perinseum.     After  delivery  of  the 
head  external  rotation  takes  place. 

Mechanism  of  the  left  mentum  anterior  'presentation.  As  before, 
extension  makes  the  chin  descend  lower  than  the  forehead.  As 
soon  as  the  chin  reaches  the  pelvic  floor  it  is  rotated  forward  to  the 
right  and  toward  the  middle  line,  the  chin  is  then  delivered  and 


Fig.  103. — Diagram  showing  Delivery  of  Head  in  Face  Presentation 

(Williams). 

flexion  follows  as  before,  causing  the  mouth,  nose,  eyes,  and  fore- 
head to  appear  successively,  after  which  the  occiput  glides  over  the 
perinseum. 

MANAGEMENT 

When  hydramnios  is  present  abnormal  presentations  are  fre- 
quent. When  it  is  a  face  presentation  it  is  desirable  to  change 
to  a  vertex  before  the  liquor  amnii  has  all  come  away.  (See 
Treatment  of  Hydramnios.) 

When  there  is  a  flat  pelvis  it  is  always  better  to  turn.  When 
there  is  a  generally  contracted  pelvis  it  is  better  to  change  to  a 
vertex  presentation  or  to  turn;  probably  version  is  the  safer 
procedure. 

In  the  great  majority  of  cases  Nature  can  complete  the  delivery 
without  great  difficulty.  Such  being  the  case,  it  is  not  necessary 
for  the  accoucheur  to  risk  much  in  efforts  to  change  the  presen- 
tation according  to  the  methods  described  by  some  obstetricians. 


FACE    PRESENTATION  173 

Active  interference  is  therefore  unnecessary,  excepting  in  the  cases 
above  referred  to. 

Among  the  methods  recommended  the  following  are  probably 
the  best,  although  1  should  not  advise  physicians  to  place  much 
reliance  on  them. 

Herman's  Method  by  Pressing  on  the  Face  and  the  Occiput. — 
Put  tu'o  fingers  in  the  vagina  and  the  other  hand  on  the  alxlomen, 
press  the  face  up  by  pressure,  first  on  the  jaws  and  then  on  the  fore- 
head, and  at  the  same  time  press  the  occiput  down  with  the  exter- 
nal hand.  If  you  have  succeeded  in  pressing  the  forehead  above 
the  pelvic  brim,  then  use  both  hands  outside,  pressing  the  occiput 
downward  into  the  pelvis  with  the  one  hand  and  pressing  the  face 
upward  and  tow^ard  the  middle  line  with  the  other. 

Schatz's  Method. — Raise  the  shoulders  and  press  them  down 
toward  the  dorsal  aspect  of  the  child  so  as  to  undo  the  extension 
of  the  spine,  at  the  same  time  steadying  or  raising  the  breech  with 
the  other  hand  applied  near  the  fundus,  so  as  to  make  the  long  axis 
of  the  child  conform  to  that  of  the  uterus:  and  finally,  press  the 
breech  directly  downward.  As  the  child  is  raised  the  occiput  is 
allowed  to  descend,  and  then  as  the  body  is  bent  forward  head 
flexion  is  produced  by  the  resistance  of  the  side  walls  of  the 
pelvis.  The  proper  time  for  this  manipulation  is  previous  to 
rupture  of  the  membranes. 

When  the  head  is  in  the  pelvic  cavity,  with  the  chin  toward  the 
front,  and  the  os,  vagina,  and  vulva  are  fully  dilated,  apply  the 
forceps  if,  after  waiting  one  or  two  hours,  satisfactory  progress  is 
not  being  made. 

When  the  head  is  low  in  the  pelvis  with  the  chin  posterior,  and 
the  OS,  vagina,  and  vulva  are  fully  dilated,  one  should  wait  for  a  cer- 
tain time,  one  or  two  hours,  with  the  hope  that  the  chin  will  rotate 
to  the  front.  If  this  does  not  happen,  the  patient  should  be  fully 
anaesthetized,  the  whole  hand  is  introduced  into  the  vagina,  the 
face  is  grasped  with  the  thumb  on  one  side  and  fingers  on  the  other 
and  the  head  is  turned  so  as  to  bring  the  chin  to  the  front  by  the 
shortest  route ;  at  the  same  time,  with  the  other  hand  on  the  abdo- 
men, an  effort  is  made  to  press  the  anterior  shoulder  in  the  same 
direction.  I  shall  again  refer  to  this  procedure  in  speaking  of 
difficult  occipito-posterior  positions. 

Herman,  who  has  given  the  most  definite  instructions  as  to  this 
form  of  procedure,  tells  us  that  when  the  chin  points  directly  back- 


174    FACE  AND  BEEECH  PEESBNTATIONS 

ward  we  should  observe  in  which  obHque  diameter  the  shoulders 
lie,  and  move  the  chin  in  the  same  direction  as  that  in  which  we 
press  the  anterior  shoulder  to  get  it  to  the  front.  When  the  chin 
is  brought  to  the  front  we  should  apply  forceps  immediately  and 
deliver. 

If  we  are  unable  to  dehver  by  any  of  the  methods  described 
nothing  remains  but  a  serious  operation  such  as  Csesarean  section, 
symphysiotomy,  or  embryotomy.  As  the  chances  of  delivering  a 
living  child  at  this  time  are  very  poor  the  operation  of  embryotomy 
is  the  one  most  commonly  performed. 

Prognosis.  The  foetal  mortahty  is  from  10  to  15  per  cent.,  and 
the  maternal  mortality  is  a  Httle  above  the  normal.  Labor  is 
usually  slow. 

Treatment. — The  treatment  may  be  summed  up  as  follows : 

Keep  the  patient  in  bed  and  preserve  the  membranes  intact  as 
long  as  possible.  No  interference  is  required,  as  a  rule.  When 
there  is  a  flat  pelvis  or  prolapse  of  the  umbilical  cord  employ  podahc 
version  (Diihrssen).  Schatz's  method,  producing  "universal  flex- 
ion "  of  foetus  by  external  manipulations,  or  Herman's  method 
is  occasionally  practicable.  After  the  os  is  dilated  the  mem- 
branes may  be  ruptured  and  the  hand  introduced  into  the  uterus 
may  flex  the  head.  Forward  rotation  of  chin  may  be  assisted 
by  pressing  the  forehead  upward  and  somewhat  backward,  and 
occasionally  by  drawing  the  chin  downward  and  somewhat  for- 
ward by  two  fingers  hooked  over  it  during  an  interval  between 
pains.  It  may  be  necessary  to  apply  the  forceps,  or  perform  Csesa- 
rean section,  or  symphysiotomy  if  child  is  ahve,  or  embryotomy  if 
child  is  dead. 

Head  Molding  and  Caput  Succedaneum. — The  vault  of  the 
head  becomes  flattened  and  pushed  backward,  while  the  frontal 
and  occipital  bones  are  bulged  and  curved.  The  diameters  short- 
ened are  the  suboccipito-bregmatic  and  the  cervico-bregmatic. 
The  diameters  lengthened  are  the  occipito-frontal  (considerably) 
and  the  occipito-mental  (shghtly). 

The  caput  succedaneum  will  be  found  to  extend  from  the  an- 
terior angle  of  the  mouth  over  the  cheek  to  the  level  of  the  eyes 
and  perhaps  to  the  other  half  of  the  face.  The  disfigurement  is 
so  great  that  the  friends  should  be  warned  before  dehvery,  and  the 
mother  should  not  be  allowed  to  see  the  child  until  the  swelhng  has 
to  some  extent  subsided. 


BREECH    PRESENTATION"  175 

BROW  PRESENTATION 

At  one  stage  during  the  change  from  vertex  to  face  presenta- 
tion we  have  what  is  known  as  brow  presentation,  the  prominence 
of  the  forehead  being  the  presenting  part.  This  is  due  to  the  fact 
that  the  two  arms  of  the  head  lever  balance  each  other.  Generally 
in  such  a  presentation  we  can  feel  the  bridge  of  the  nose  or  the 
supra-orbital  ridges  on  one  side  of  the  pelvis  and  the  anterior  fon- 
tanelle  on  the  other,  at  the  same  time  the  frontal  suture  occupies 
the  same  position  in  the  center  of  the  pelvis  that  the  sagittal  holds 
in  vertex  presentations.  This  is  a  very  difficult  presentation, 
although  it  is  barely  possible  that  without  interference  dehvery 
may  take  place.  During  labor  the  forehead  generally  turns  to  the 
front  and  the  occiput  to  the  rear,  the  following  parts  appear  suc- 
cessively at  the  vulva,  forehead,  eyes,  and  nose,  after  which  the 
vertex  and  occiput  ghde  over  the  perinaeum,  then  the  mouth  and 
chin  emerge  under  the  pubic  arch.  The  prognosis  in  such  cases  is 
bad  for  both  mother  and  child. 

Treatment. — Early  in  labor  we  should  endeavor  by  manipula- 
tion to  change  the  presentation  into  a  vertex  or  face.  If  we  are 
unable  to  do  this  try  to  perform  podalic  version.  Sometimes  the 
head  may  be  delivered  with  the  forceps.  If  all  such  efforts  fail, 
caesarean  section,  symphysiotomy,  or  embryotomy  becomes  neces- 
sary. 

BREECH  PRESENTATION 

In  a  certain  proportion  of  cases  the  breech  presents  instead  of 
the  head.  The  dangers  to  the  child  in  breech  labors  are  fairly  well 
known  but  not  always  fully  appreciated.  In  the  most  skilled 
hands  probably  7  to  10  per  cent,  of  the  children  are  still-born.  In 
some  Charities,  we  are  told  by  Herman  that  30  per  cent,  or  more 
perish  during  dehvery.  In  other  words,  the  excess  in  the  mor- 
tality rate  depending  on  want  of  skill  in  management  sometimes 
amounts  to  20  per  cent,  or  more.  The  mortaUty  among  children 
in  breech  deliveries  conducted  by  midwives  in  Great  Britain  is 
simply  appalUng.  A  country,  however,  which  by  act  of  Parhament 
converts  the  ordinary  midwife  into  a  legalized  obstetrician,  must 
inevitably  suffer  seriously  from  such  extraordinary  legislation. 

Carelessness  and  ignorance  as  to  proper  methods  of  conducting 

breech  cases  are  not,  however,  confined  to  midwives.     My  own 

experience  and  observation  lead  me  to  believe  that  many  physi- 
13 


176  FACE    AI^D    BREECH    PRESENTATIONS 

cians  neglect  to  use  proper  and  systematic  methods  in  the  manage- 
ment of  these  cases. 

Version  before  labor  in  breech  presentation  has  become  some- 
what popular  in  London,  England,  during  the  last  few  years,  but 
is  not  often  performed  in  the  United  States  or  Canada.  The  pro- 
cedure is  sometimes  easy  of  performance  and  fairly  safe  in  skilled 
hands.  One  can  not,  however,  in  any  case  be  certain  of  getting  a 
good  vertex  position  after  the  version.  It  is,  I  think,  better  for 
the  general  practitioner  to  make  no  attempt  at  version,  but  to  em- 
ploy proper  methods  of  extracting  the  child  as  quickly  and  safely 
as  possible. 

The  main  points  as  to  classification,  prognosis,  causes,  diag- 
nosis, mechanism,  and  preparation  may  be  summarized  as  follows, 
before  speaking  in  detail  as  to  the  management  of  breech  delivery. 

Pelvic  presentations  are  subdivided  into:  1,  Breech;  2,  knee; 
3,  footling.  The  mechanism  is  nearly  the  same  in  all;  the  fre- 
quency is  2  to  3  per  cent. ;  the  prognosis  is  good  for  mother,  bad 
for  child.    The  child  is  still-born  1  in  10  cases,  some  say  1  in  5  cases. 

The  dangers  to  child  are :  1,  Suffocation  from  respiratory  efforts 
before  delivery  of- the  head;  2,  asphyxia  from  compression  of  cord 
after  umbilicus  has  emerged  from  vulva ;  3,  stoppage  of  the  foet<sl 
circulation  from  uterine  compression  of  placenta  while  head  is  in 
vagina;  4,  injuries  from  efforts  to  deliver. 

The  causes  are :  Premature  birth,  twin  pregnancy,  ioetal  mon-^ 
strosity,  excess  of  liquor  amnii,  death  of  foetus,  hydrocephalus, 
laxity  of  uterine  walls,  placenta  prsevia,  contracted  pelvis. 

Diagnosis. — Abdominal  Examination.  The  head  is  at  fundus 
uteri  (generally  on  one  side),  there  are  no  small  parts  (limbs)  felt 
beside  the  head,  the  heart  sounds  are  heard  above  the  level  of  the 
umbilicus,  the  limbs  are  felt  lower  down. 

Vaginal  Examination.  The  bag  of  membranes  is  broad  and 
''pudding  shaped"  (Parvin),  the  bag  of  membranes  descends  low 
while  the  presenting  part  is  high,  the  breech  is  gofter  than  the  head 
and  without  sutures,  fontanelles,  or  hair. 

The  following  parts  may  be  felt :  Trochanter  major,  groove  be- 
tween buttocks,  genitals,  spinous  processes,  sacrum,  coccyx,  and 
•anus.     (Anus ''bites,"  Winckel.)     Meconium  escapes. 

Differential  Diagnosis  of  Knee  and  Elbow.  The  knee  is  broader, 
and  has  patella  and  two  tuberosities  with  slight  depression  between 
them  instead  of  sharp  projections  of  olecranon. 


BEEF.CH    PRESENTATION  177 

Differential  Diagnosis  of  Foot  and  Hand.  In  the  foot  the  toes 
are  nearly  in  a  line  and  not  very  movable,  the  heel  projects  with 
mUleoli  above  it.  The  internal  border  is  broader  and  thicker 
than  the  external.  The  foot  is  at  right  angles  to  the  leg.  In  the 
hand  the  thumb  is  shorter  than  the  fingers,  and  may  be  separated 
from  the  index  finger;  the  thumb  and  fingers  are  more  movable 
than  the  toes. 

Mechanism. — Positions.  There  are  four  positions  as  in  head 
presentations.  The  sacrum  in  each  points  in  same  direction  as 
occiput  in  vertex  presentation,  but  mechanism  differs,  because 
the  transverse  diameter  of  the  child's  pelvis  is  longer  than  the 
antero-posterior,  and  a  hip  instead  of  sacrum  rotates  to  front. 
The  positions  are : 

1.  Left  sacro-anterior — L.  S.  A. 

2.  Right  sacro-anterior — R.  S.  A. 

3.  Right  sacro-posterior — R.  S.  P. 

4.  Left  sacro-posterior — L.  S.  P. 

The  order  of  frequency  is  1,  3,  2,  4. 

MECHANISM  OF  FIRST   OR  LEFT   SACRO-ANTERIOR  POSITION 

During  descent  the  left  or  anterior  hip  becomes  lower  than  the 
other.     This  movement  corresponds  to  flexion. 

When  the  anterior  hip  strikes  the  lateral  half  of  the  posterior 
segment  of  the  pelvic  floor  it  is  rotated  forward  to  the  pubic  arch. 

This  brings  the  intertrochanteric  diameter  into  the  antero- 
posterior diameter  of  the  outlet. 

While  the  anterior  hip  is  passing  under  the  pubic  arch  the  pos- 
terior hip  passes  over  the  perinsBum  in  a  movement  that  corre- 
sponds to  extension.  This  brings  about  "lateral  flexion  of  the 
trunk."  The  shoulders  come  into  the  brim  with  their  long  dia- 
meter transverse ;  into  pelvis  with  long  diameter  oblique ;  emerge 
from  outlet  with  long  diameter  antero-posterior. 

The  head  comes  into  brim  with  its  long  axis  in  the  transverse 
diameter,  and  rotates  during  descent,  the  occiput  coming  to  the 
front. 

Stages  in  Delivery. — The  stages  in  delivery  are : 

\.  Compression  or  molding.  Lessening  of  presenting  part 
through  propelling  and  resisting  forces. 


178  FACE    AND    BREECH    PEESENTATIONS 

2.  Descent  of  breech  to  pelvic  floor. 

3.  Rotation  of  anterior  hip  into  pubic  arch,  left  hip  in  first 
position. 

4.  Delivery  of  breech  and  trunk. 

5.  Descent  of  head  coming  into  oblique  diameter, 

6.  Rotation  of  occiput  to  front. 

7.  Delivery  of  head  by  extension:  first  chin,  then  face,  fore- 
head, etc. 

In  all  head-last  cases  the  chin  should  be  born  first  (Fothergill). 

Management. — The  following  rules  are  recommended : 

Make  all  preparations  for  restoring  suspended  animation  in  the 
child. 

Instruct  the  nurse  to  have  ready  at  hand  water  for  hot  and 
cold  bath  for  the  child. 

Have  at  hand  the  soft  rubber  tube,  with  bulb  attached,  to  clear 
child's  pharynx. 

Tell  the  friends  the  nature  of  the  case  and  the  risk  to  the  child. 

Avoid  traction,  because  it  may  cause  extension  of  arms  over 
head  and  extension  of  head  itself. 

Leave  membranes  intact  if  possible  until  cervix,  vagina,  and 
vulva  are  dilated  or  dilatable. 

Place  patient  in  cross-bed  position. 

The  last  rule  is  one  of  extreme  importance.  The  patient  should 
be  placed  on  her  back  across  the  bed,  with  the  buttocks  at  the  edge 
of  the  bed  in  the  lithotomy  or  Walcher's  position.  One  can  not 
give  proper  assistance  with  the  patient  in  any  other  position  in  the 
majority  of  cases.  The  patient  should  be  put  in  this  position 
shortly  before  delivery.  Diihrssen's  rule  is  an  excellent  one,  "  Do 
this  in  the  multipara  when  the  breech  enters  the  vagina,  in  the 
primipara  when  it  is  on  the  point  of  delivery." 

Preparation  of  Physician. — He  should  make  bare  both  arms  up 
to  the  shoulders,  or  as  nearly  so  as  possible,  and  cleanse  the  hands 
and  arms  thoroughly.  One  might  ask  should  not  both  hands  and 
arms  be  clean  in  any  case?  Yes,  they  should ;  but  very  frequently 
even  careful  practitioners  have  only  one  hand  and  arm  laid  bare. 
In  certain  cases  the  physician  can  manage  much  better  by  with- 
drawing one  hand  after  a  certain  manipulation,  and  introducing  the 
other  hand  for  another  manipulation. 

The  critical  time  has  come  when  the  child  is  born  as  far  as  the 
umbilicus.     The  cord  may  be  pulled  down  slightly,  and  should  be 


BKEECH    PRESENTATION"  179 

watched  carefully.  Any  efforts  to  place  it  in  a  favorable  position, 
as,  for  instance,  in  front  of  one  of  the  sacro-iliac  joints,  as  some- 
times recommended,  are,  1  think,  useless. 

The  great  danger  which  arises  is  compression  of  the  cord  be- 
tween the  head  and  pelvic  wall.  If  pulsation  in  the  cord  ceases  the 
child  will  die  in  from  four  to  eight  minutes  if  not  delivered.  Prompt 
action  is  therefore  necessary,  but  traction  should  be  avoided  before 
deUvery  of  shoulders,  if  possible.  Pressure  on  the  fundus  should  be 
made.  An  intelligent  and  skilled  nurse  is  of  much  service  in  such 
a  case.  If  the  nurse  is  not  skilled  she  should  be  told  how  to  press 
on  the  fundus  while  the  physician  is  handling  the  child.  She 
should  place  her  two  hands  on  the  fundus  and  press  downward 
while  the  thorax  and  shoulders  are  being  expelled.  She  should 
still  press  on  the  fundus,  with  the  object  of  pushing  the  head 
through  the  pelvis.  It  is  well  at  this  stage  to  place  the  hands 
immediately  above  the  symphysis  pubis;  locate  the  head  and 
intelligently  force  it  in  the  right  direction,  which  is  down- 
ward and  slightly  backward,  while  the  physician  is  carrying  the 
child  forward,  and  at  the  same  time  using  traction.  If  the  phy- 
sician has  no  assistant,  he  may  press  on  the  head  with  one  hand 
above  the  symphysis,  while  the  other  seizes  the  legs  or  body  of 
the  child. 

Rule  as  to  Traction. — Avoid  traction  if  possible  before  the  arms 
are  expelled.  Use  traction  after  the  shoulders  are  born  by  shoulder- 
jaw  traction  with  suprapubic  pressure,  as  described  under  Diffi- 
cult Pelvic  Delivery. 

Sometimes  it  is  well  to  wrap  flannel  around  the  exposed  parts  of 
the  child  to  prevent  respiratory  efforts  which  may  be  induced  by 
contact  with  the  cold  air.  This,  however,  often  becomes  an  im- 
pediment to  skilful  manipulation  and  quick  delivery,  and  is  there- 
fore in  many  cases  useless  if  not  harmful. 

DiflBicult  Breech  Delivery. — Different  circumstances  may  make 
a  breech  delivery  difficult. 

1.  The  breech  may  not  descend  into  the  pelvis  after  the  parts 
are  fully  dilated. 

2.  The  breech  may  descend  into  the  pelvis,  but  the  uterine 
contractions,  together  with  pressure  on  fundus,  may  fail  to  expel 
the  foetus. 

3.  Delivery  fairly  easy  up  to  a  certain  point  may  become  diffi- 
cult from  extension  of  child's  arms  beside  the  head. 


180  FACE    AND    BREECH    PRESENTATIONS 

In  all  these  cases  active  interference  with  more  or  less  traction 
becomes  necessary. 

If  the  breech  does  not  descend  into  pelvis  within  an  hour  or  two 
after  the  os  is  fully  dilated  the  following  directions  may  be  fol- 
lowed : 

Bring  down  a  leg.  It  is  better  as  a  rule  to  anaesthetize  the 
patient  and  perform  the  operation  before  all  the  liquor  amnii  has 
escaped. 

Pass  up  the  hand  with  its  palm  toward  the  child's  abdomen. 

Support  the  uterus  with  the  other  hand  on  fundus  externally. 

Seize  the  anterior  foot  if  possible. 

If  the  legs  are  extended  on  the  thighs  so  that  the  feet  are  close 
to  the  head,  the  hand  must  be  passed  up  to  the  fundus.  On  reach- 
ing a  knee  press  it  outward  and  backward,  then  push  the  hand 
farther  and  seize  the  instep  or  foot.  Carry  the  foot  to  the  opposite 
side  of  the  foetus,  then  bring  it  down. 

When  interference  becomes  necessary,  after  the  breech  has 
descended  into  pelvis,  it  is  better  even  then  to  endeavor  to  pass  up 
the  hand  and  bring  down  a  foot ;  but  full  ansesthetization  is  desir- 
able, and  great  gentleness  and  caution  are  necessary. 

It  is  especially  dangerous  to  wait  until  the  ring  of  Bandl  is  high 
up,  showing  that  the  lower  uterine  segment  is  much  stretched  and 
thinned. 

In  some  cases  it  is  impossible  to  bring  down  a  leg  safely.  In 
such  a  contingency  the  following  alternative  procedures  are  recom- 
mended. 

Digital  Traction. — Sometimes  when  breech  is  close  to  perinseum 
digital  traction  may  be  sufficient.  Hook  index  finger  in  the  flex- 
ure of  anterior  groin  and  use  traction,  or  make  traction  alternately 
on  the  anterior  and  posterior  groin,  or  make  traction  simultane- 
ously on  both  groins,  using  the  two  index  fingers. 

Soft  Fillet. — A  soft  fillet,  such  as  an  oiled  handkerchief,  may 
be  passed  round  one  (the  anterior  if  possible)  or  both  thighs,  so  as 
to  press  on  the  groin  or  groins  (not  the  thighs.)  A  gum  elastic 
catheter  threaded  with  a  loop  of  string  may  be  used  to  pass  the 
fillet  around  the  groin. 

A  blunt  hook  may  be  pressed  over  anterior  thigh,  but  it  is 
dangerous  to  a  living  child. 

Forceps  may  be  applied,  the  axis-traction  being  probably  the 
best. 


BREECH    TRESENTATJON  181 

Embryulcia. — In  certain  cases  of  serious  impaction  of  the 
breech,  in  which  a  leg  can  not  be  brought  down,  embryulcia  be- 
comes necessary.     Such  cases  fortunately  are  rare. 

Rules. — The  following  rules  for  the  liberation  of  arms  when 
extended  beside  the  head  are  recommended  : 

Elevate  child  toward  mother's  abdomen,  using  moderate 
traction. 

Try  to  liberate  posterior  arm. 

Use  hand  that  naturally  faces  abdomen  of  child  and  introduce 
until  two  fingers  reach  elbow. 

Some  prefer  to  pass  the  other  hand  along  the  back  of  the  child 
and  behind  the  posterior  arm  as  far  as  the  elbow  (Mcllwraith  pre- 
fers this  method). 

Draw  arm  across  child's  face  and  then  downward. 

Then  bring  hips  downward  and  make  traction  on  thighs,  as 
there  may  be  now  room  for  head  and  remaining  arm. 

If  not,  try  to  liberate  the  anterior  arm. 

If  unable  to  do  so,  push  child  backward  into  the  pelvis  to  avoid 
dislocating  the  atlas,  and  rotate  the  body  so  that  the  arm  that  was 
the  anterior  will  become  the  posterior. 

During  this  rotation  the  back  of  the  child  should  sweep  across 
the  front  of  the  mother's  pelvis. 

Bring  down  the  arm  as  before  with  other  hand. 

Nuchal  or  Dorsal  Displacement  of  Arm. — Very  rarely  the  arm 
is  extended  by  the  side  of  the  head  and  is  bent  at  elbow,  so  that  the 
forearm  lies  behind  the  neck. 

TreatJnent. 

1.  Place  foetal  body  downward,  pass  fingers  along  the  back 
behind  the  symphysis,  seize  the  elbow,  then  sweep  the  arm  outward 
and  over  foetal  face,  or 

2.  Rotate  foetal  body  in  a  direction  opposite  to  that  which  pro- 
duced the  displacement. 

3.  It  may  sometimes  be  necessary  to  fracture  the  arm. 
Methods  of  Delivery  of  the  After-coming  Head. — Veit-Smellie, 

Levret-Veit  or  Shoulder-jaw  Method.  Apply  two  fingers  of  one 
hand  to  lower  jaw  (in  the  mouth)  and  fingers  of  the  other  hand 
over  back  of  the  nape  of  neck  and  pull  with  both.  Dr.  Matthews 
Duncan  stated  that  from  his  experiments  he  proved  that  46 
pounds  may  be  appHed  in  dragging  down  the  lower  jaw  in  some 
cases  without  producing  any  injury  to  the  parts. 


182 


FACE    AND    BEEECH    PEESENTATIONS 


Smellie^s  Method.  Apply  fingers  of  one  hand  over  superior 
maxillary  bones  at  sides  of  nose  and  pull  face  down,  while  fingers 
of  other  hand  push  occiput  toward  sacral  cavity. 

Wigand-Martin  Method.  Place  two  fingers  of  the  one  hand, 
whose  palm  corresponds  to  the  face,  in  the  mouth,  pulling  on  the 
lower  jaw— the  baby  being  on  the  same  arm  in  such  a  way  that  the 
abdomen  lies  on  the  forearm  with  the  baby's  arms  and  thighs  on 
either  side — the  other  hand  pressing  over  abdomen  on  the  head. 

Prague  Method.  Take  the  child's  ankles  in  one  hand  and  apply 
the  fingers  of  other  hand  over  the  nape  of  the  neck  and  pull  first 


Fig.  104. — Prague  Method  of  Extracting  the  Head  (Lusk). 


downward  and  backward  until  the  head  has  entered  the  pelvis, 
and  then  upward  and  forward. 

Forceps.     Preferably  the  axis-traction. 

Delivery  after  Embryulcia. 

Malrotation  of  Head.  When  the  occiput  remains  in  the  hollow 
of  the  sacrum  hold  the  head  and  trunk  by  the  shoulder-jaw,  grasp 


BREECH    PRESENTATION 


18o 


and  rotate  them  until  occiput  comes  to  the  front  and  then  com- 
plete delivery. 

If  rotation  can  not  be  accomplished  in  this  way,  some  say  that 


Fig.  105. — Shoulder-jaw  Traction,  downward  and  slightly  backward, 
WITH  Suprapubic  Pressure. 


the  body  of  the  child  must  be  swung  backward  instead  of  forward 
and  the  chin  and  face  brought  out  under  the  pubic  arch. 

Formerly  the  aftercoming  head  was  generally  extracted  with 
forceps,  but  since  the  admirable  continental  methods  have  been 


Fig.  106. — Shoulder-jaw  Traction,  chiefly  forward,  with  Suprapubic 

Pressure. 

adopted  the  use  of  this  instrument  is  rarely  necessary.  The  Prague 
method  is  said  to  be  dangerous  for  the  child.  This  is  not  true  when 
the  method  is  used  with  ordinary  care.     It  answers  w^ell  in  some 


184  FACE    AND    BEEECH    PRESENTATIONS 

cases,  as  the  head  may  thus  be  deUvered  easily  and  quickly.  It  is 
not  so  efficient  in  difficult  cases  as  some  of  the  other  methods. 

It  is  important  to  take  one  definite  line  of  action.  The  follow- 
ing is  recommended : 

Pull  on  nape  of  neck  and  lower  jaw,  the  assistant  at  the  same 
time  pressing  on  the  head  through  the  abdominal  walls.  This  is 
called  in  another  section  shoulder-jaw  traction  with  suprapubic 


Fig.  107. — Shoulder-jaw  Traction,  upward  Traction  with  Hand  grasping 
THE  Ankles,  and  Suprapubic  Pressure. 


pressure  and  is  practically  a  combination  of  the  Veit-Smellie  and 
the  Wigand-Martin  methods.  This  will  accomplish  delivery  in  a 
short  time  in  the  great  majority  of  cases. 

If  it  fails,  try  the  Smellie  method.  Remove  the  fingers  from 
mouth,  and  apply  them  at  the  sides  of  the  nose,  and  slip  the  fingers 
of  the  other  hand  up  to  occiput.  Some  object  because  "greased  " 
fingers  can  not  do  much  against  the  ''slippery  skin"  of  the  foetus. 
This  is  to  some  extent  true,  but  the  aim  should  be  now  to  increase 
the  flexion  of  the  head,  then  go  back  to  jaw  and  shoulders,  and 
again  pull.  Two  assistants  may  be  profitably  employed  in  some 
cases.  Let  one  press  on  the  head  from  above,  and  the  other  hold 
the  ankles  upward,  using  traction,  while  the  operator  uses  the 


MULTIPLE    OR    I'LUKAL    PREGNANCIES  185 

shoulder-jaw  pull.  This  is  a  combination  of  the  Veit-Smellie, 
Wigand-Martin,  and  Prague  methods,  and  is  sometimes  the  most 
efficient  plan  that  can  be  adopted.  I  prefer  to  call  it  shoulder- 
jaw  traction,  upward  traction  witli  hands  grasping  the  ankles,  and 
suprapubic  pressure. 

While  it  may  be  conceded  that  the  methods  described  are  the 
best  in  the  majority  of  cases,  the  forceps  should  not  be  ignored. 
This  instrument  properly  sterilized  should  be  in  readiness.  It 
occasionally  happens  that  the  operator  can  extract  the  head  with 
the  forceps  after  the  "continental"  methods  have  failed.  Before 
applying  the  forceps  draw  the  child  forward  and  upward  toward 
the  mother's  abdomen,  and  introduce  the  blades  from  behind. 

MULTIPLE  OR  PLURAL  PREGNANCIES 

When  the  uterus  contains  two,  three,  four,  or  five  fcetuses  the 
pregnancy  is  multiple  or  plural.  The  following  terms  are  used  ac- 
cording to  the  numbers  :  Two  foetuses,  twins ;  three,  triplets ;  four, 
quadruplets ;  five,  quintuplets.  The  corresponding  names  applied 
to  the  pregnancies  are  double,  triple,  quadruple,  quintuple.  I  think 
there  is  no  authentic  record  of  more  than  five  children  at  a  birth. 

Frequency.  Double  pregnancy  occurs  about  once  in  100  preg- 
nancies; triple,  once  in  6,000;  quadruple,  once  in  400,000;  quin- 
tuple, extremely  rare. 

Sexes.  The  sexes  of  twins  are  as  follows :  Both  girls  in  30  per 
cent.,  both  boys  in  34  per  cent.,  a  boy  and  a  girl  in  36  per  cent,  of 
cases. 

TWINS 

Uniovular  Twins. — Twins  may  develop  either  from  a  single 
ovum  or  from  two  distinct  ova  discharged  from  the  same  Graafian 
folhcle.  The  two  Graafian  follicles  may  exist  in  one  ovary,  or  each 
of  the  tw^o  may  exist  in  a  different  ovary.  In  the  one  case  two 
corpora  lutea  will  be  found  in  one  ovary ;  in  the  other  case  one  cor- 
pus luteum  will  be  found  in  each  ovary.  There  are  two  varieties 
of  uniovular  twin  pregnancies : 

(a)  The  twins  are  developed  from  two  centers  in  two  yolks. 

(b)  The  twins  are  developed  from  the  two  halves  of  one  center 
— that  is,  the  two  portions  formed  by  a  splitting  of  a  single  area 
germinativa. 

When  twins  are  developed  from  two  centers  in  one  ovum  the 


186 


MULTIPLE    PREGNANCIES 


placenta,  the  chorion,  and  the  reflexa  are,  as  a  rule,  common  to 
both.  This  is  generally  recognized  as  a  fact,  but,  strictly  speaking, 
we  do  not  find,  even  in  the  uniovular  twin  pregnancies,  a  single 
placenta,  because  in  all  cases  the  embryonic  portion  is  of  individ- 
ual origin.  We  have  really  a  double  placenta  in  early  foetal  life; 
the  two  placentae  are,  however,  in  close  proximity  and  a  certain 
amount  of  fusion  takes  place  with  more  or  less  superficial  and  deep 
anastomosis  of  the  blood-vessels.  At  full  term,  therefore,  we  have 
apparently  a  single  placenta,  and  for  practical  purposes  we  should 

consider  it  as  such.  In  most  in- 
stances each  foetus  is  contained 
in  its  own  amnion;  in  certain 
cases,  however,  we  find  only  a 
single  amnion,  the  two  having 
become  merged  into  one,  the 
original  wall  separating  them 
having  undergone  absorption. 

It  is  said  by  some  authors 
that  twins  from  one  egg  are  of 
the  same  sex.  This  is  not  always 
true  with  respect  to  twins  de- 
veloped from  two  yolks  in  the 
one  egg.  Under  such  circum- 
stances twins  may  be  both  girls, 
both  boys,  or  a  boy  and  a  girl. 
There  is  frequently  a  great  difference  in  twins  both  as  to  size 
and  development.  Such  disparity  is  common  in  uniovular  twin 
pregnancies  in  consequence  of  the  anastomoses  existing  between 
the  placental  vessels  of  the  two  embryos.  The  growth  of  the 
embryos  varies  according  to  the  quantity  of  blood  supplied  to 
each.  Schultze  reports  a  striking  example  where  one  child  at 
birth  was  nearly,  if  not  quite,  mature,  while  the  other  presented 
the  appearance  of  a  six  weeks'  foetus. 

Acardiac  Monster.  When  one  embryo  is  weaker  than  the  other 
the  heart  of  the  stronger  may  overcome  that  of  the  other,  the  blood 
is  forced  from  the  placenta  along  the  umbilical  arteries  of  the  more 
feeble  embryo.  There  is  not,  however,  sufficient  force  to  carry 
the  current  to  the  upper  parts  of  the  body.  As  a  consequence,  the 
heart  and  all  portions  of  the  foetus  above  the  heart  remain  unde- 
veloped and  the  result  is  an  acardiac  monster, 


Fig.    108. — Diagram    showing    Posi 
TioN  OF  Twins  in  Utero. 

One  head  and  one  breech  presenting. 


MULTIPLE    OR   PLURAL   PREGNANCIES 


187 


Probably  the  most  extreme  form  of  disparity  between  twins  is 
when  one  grows  and  thrives  at  the  expense  of  the  other.  In  such 
a  case  the  favored  one  ab- 
sorbs all  the  nutriment  origi- 
nally intended  for  both ;  the 
weaker  embryo  soon  dies, 
and  becomes,  when  squeezed 
for  some  time  against  the 
uterine  wall,  a  foetus  papy- 
raceus,  or  degenerates  into 
some  form  of  mole.  Such 
blighted  foetus,  or  mole, 
being  excluded  from  the  air, 
does  not  become  putrid  be- 
fore the  onset  of  labor.  A 
foetus  papyraceus  is  some- 
times found  in  triplet  preg- 
nancy when  two  foetuses 
survive  (Fig.  109). 

The  second  variety  of 
uniovular  twin  pregnancy  is 
interesting,  and  at  the  same 
time  fortunately  rare.  Gen- 
erally, if  not  alw^ays,  in  such 
cases  there  is  a  pathological 
condition.  In  certain  cases 
the  single  area  germinativa 
is  completely  and  evenly  di- 
vided, resulting  in  the  devel- 
opment of  twins  enclosed  in 
the  same  amnion.  Accord- 
ing to  Ahlfeld,  the  division 
when  complete  produces 
twins  enclosed  in  the  same 
amnion,  which  are  not  only 
of  the  same  sex  but  bear  to 
one  another  through  life  the 
most  striking    similarity   as 

regards  appearance,  physical  peculiarities,  as  well  as  mental  and 
moral  characteristics.     When,  however,  the  division  is  incomplete, 


Fig.  109. — Fcetus  Papyraceus. 

Triplet  pregnancy,  other  two  born  alive 
and  liealtliy.  (Dr.  Neff  Ingersoll,  Univ. 
Tor.  Museum.) 


188 


MULTIPLE    PREGNANCIES 


the  result  is  conjoined  twins,  forming  one  of  the  most  frequently 
occurring  varieties  of  double  monster. 

Binovular  Twins. — When  the  twins  develop  from  two  ova  each 
foetus  is  surrounded  by  its  own  amnion  and  chorion.  If  the  ova 
in  the  decidual  membrane  are  separated  sufficiently  far  from  each 


Fig.  110. — Triplets  from  TVo  Eggs. 

One  sac,  a,  contains  one  placenta  and  two  fcBtuses,  second  sac,  h,  b,  one  placenta 
and  one  foetus.     Both  sacs  ruptured. 


other  the  two  placentae  will  be  separate,  and  each  ovum  will  have 
its  own  decidua  reflexa.  Sometimes,  when  situated  nearer  each 
other,  the  two  placentse  are  united  at  their  borders,  each  having 
its  own  independent  circulation.  This  variety  of  twin  pregnancy 
(developed  from  two  eggs)  is  by  far  the  most  common,  and,  as  a 
consequence,  there  are  two  distinct  bags  of  membranes  in  a  large 
majority  of  cases  (about  85  per  cent.). 

Triplets  may  develop  from  three  distinct  ova,  or  two  from  a  single 
ovum  and  one  from  a  second  ovum.  In  three-egg  triplets  there  are 
three  placentse  and  three  distinct  bags  of  membranes  (Fig.  111).  . 


MULTIPLE    OR    PLURAL   PREGXANCIES 


189 


In  two-egg  triplets  there  are  one-egg  twins,  with  generally  one 
placenta,  chorion,  antl  reflexa,  and  a  third  fcetus  with  its  placenta 
and  })ag  of  moiiibraiics  (Fig.  110). 

Superfecundation. — Generally,  in  connection  with  binovular 
twins,  we  consider  that  two  ova  have  been  fertiUzed  at  one  coitus. 
But  we  know  that  one  egg  may  be  fertihzed  at  one  time  and  a 
second  at  another  time.  This  has  been  proved  by  the  fact  that  a 
woman  has  been  delivered  of  twins,  of  which  one  was  black  and 
the  other  white.  In  such  a  case  as  this  one  egg  must  have  been 
fertihzed  by  a  black  father  and  the  other  by  a  white.     Such  fer- 


FiG.  111. — Triplets  from  Three  Eggs. 

Three  placentae,  three  sets  of  membranes ;  h,  h,  h,  heads;  c,  c,  c,  cords;  p,  p,  p,  pla- 
centae.     (Tor.  Univ.  Museum.) 


tilization  of  two  eggs  is  called  superfecundation,  and  has  occurred 
during  one  intermenstrual  period. 

Superfoetation. — When  one  egg  is  fertilized  and  lies  within  the 
uterine  cavity  we  have  a  normal  pregnancy.  If,  in  connection  with 
a  subsequent  menstrual  period  a  second  egg  is  fertilized  we  have 
what  is  called  superfoetation.     Many  are  the  discussions  which 


190  MULTIPLE    PEEGNANCIES 

have  taken  place  respecting  the  possibihty  of  such  an  occurrence. 
Twins  show  frequently  a  great  disparity  and  such  unequal  devel- 
opment has  often  been  considered  as  proof  of  superfoetation. "  A 
great  many  think  that  superfoetation  may  possibly  occur  before 
the  decidua  vera  and  reflexa  have  become  united ;  that  is  to  say, 
within  three  or  four  months  after  conception.  Spiegelberg  con- 
siders that  superfoetation  is  a  physiological  impossibility,  because 
physiological  ovulation  always  ceases  as  soon  as  pregnancy  has 
commenced. 

It  is  well  to  remember  that  twin  pregnancies  occasionally  occur 
in  which  one  embryo  is  developed  within  and  the  other  outside 
the  uterus. 

Pathological  Conditions. — Twin  pregnancies  probably  end 
prematurely  in  more  than  half  the  cases.  One  of  the  twins  may 
survive  and  thrive  at  the  expense  of  the  other,  as  already  indicated. 
The  weaker  embryo  may  die  and  be  expelled ;  generally  the  dead 
embryo  is  not  expelled  but  becomes  a  mummified  mass.  Vesicular 
degeneration  of  the  chorion,  forming  a  hydatid  mole,  is  not  un- 
common. Monstrosities  are  somewhat  frequent.  Various  acci- 
dents may  arise  in  utero  from  crossing  and  twisting  of  the  cords. 

Presentations  of  Twins. — The  following  presentations  are  most 
frequently  met  with :  Vertex  in  both  twins,  50  per  cent. ;  vertex 
and  breech,  35  per  cent. ;  pelvis  in  both,  10  per  cent. ;  transverse 
in  one,  3  per  cent. ;  other  varieties,  2  per  cent. 

Diagnosis. — It  is  exceedingly  difficult  to  make  a  diagnosis  of 
multiple  pregnancy  with  certainty.  Unusual  enlargement  of  the 
uterus  may  create  a  suspicion  of  such  a  condition ;  the  patient  her- 
self is  apt  to  think  of  twins  when  the  uterus  is  unusually  large. 
Such  increase  in  size,  however,  furnishes  no  direct  proof  because 
it  is  quite  as  apt  to  be  due  to  the  presence  of  a  very  large  child  or 
to  an  excess  of  the  amniotic  fluid.  Occasionally  it  may  be  no- 
ticed, when  the  uterus  is  greatly  enlarged,  that  the  surface  of  the 
abdomen  is  traversed  by  a  groove.  One  may  sometimes  obtain 
trustworthy  information  by  palpation  and  auscultation.  Thus,  if 
hydramnios  were  excluded  the  recognition  of  a  number  of  differ- 
ent foetal  parts  would  point  to  the  probability  of  twin  pregnancy. 
The  probability  might  amount,  perhaps,  to  certainty  when  two 
foetal  heads  can  be  outlined  at  a  distance  from  each  other.  When 
the  foetal  heart  sounds  are  heard  at  two  remote  points  and  the 
sound  dies  away  in  the  intervening  space  it  may  be  presumed  that 


MULTIPLE    OR    PLURAL   PREGNANCIES  191 

twins  arc  present.  In  the  ftreat  majority  of  cases,  however,  no 
diagnosis  is  made  until  after  the  birth  of  the  first  child;  the  pres- 
ence of  the  second  is  then  determined  by  the  ordinary  signs,  easily 
detected  both  externally  and  internally.  It  is  practically  impos- 
sible to  make  a  certain  diagnosis  of  trij)lets  and  quadruplets. 

Diagnosis  of  tnultiplc  pregnancy.  The  uterus  is  uiuisually  large 
(this  may,  however,  be  due  to  the  presence  of  a  large  child  or  to 
hydramnios).  There  is  sometimes  a  groove  on  the  surface  of  the 
abdomen.  The  foetal  heart  sounds  are  sometimes  heard  at  remote 
points.  Two  heads  are  sometimes  felt.  Suprapubic  oedema  is 
nearly  always  present. 

Management  of  Labor. — Few  directions  are  rec^uired  as  to  the 
management  of  labor  in  multiple  pregnancies.  Put  two  ligatures 
on  the  cord  and  cut  between  them  for  fear  of  vascular  communica- 
tion between  the  placentae.  After  the  first  birth  allow  the  mother 
to  rest  for  a  time.  Keep  uterus  contracted  by  external  manipula- 
tion or  by  the  application  of  an  abdominal  binder.  After  half  an 
hour  rupture  the  second  bag  of  membranes  if  intact.  Then  aid 
delivery  if  necessary  by  external  pressure  or  by  the  use  of  the 
forceps. 


14 


PAKT  II 

PATHOLOGICAL  AND  OPERATIYE 
OBSTETEIOS 


CHAPTER  X 

DISEASES  OF  PREGNANCY 

The  pregnant  woman  is  subject  to  the  same  diseases  that 
attack  the  non-pregnant.  These  diseases  are  sometimes  called 
intercurrent  diseases  or  complications  of  pregnancy.  In  addi- 
tion, the  pregnant  woman  may  suffer  from  diseases  due  to  the 
changes  taking  place  in  the  uterus  and  the  whole  body  in  conse- 
quence of  the  growth  of  the  fructified  egg.  There  are  several 
classifications  of  these  diseases  of  pregnancy,  but  none  is  entirely 
satisfactory.  Perhaps  the  best  method  is  to  discuss  them  as  they 
affect  the  various  systems  of  the  body. 

Diseases  of  the  Digestive  Organs. — Some  of  the  diseases  of  the 
digestive  organs  are  among  the  most  common  and  sometimes  the 
most  serious.  This  is  especially  true  of  diseases  of  the  stomach 
and  intestines.  No  disease  of  pregnancy  should  be  considered 
insignificant.  On  the  contrary,  each  disorder  causes  a  certain 
amount  of  inconvenience  at  least,  sometimes  much  more  than  a 
careless  obstetrician  is  apt  to  realize.  These  diseases  are,  whether 
slight  or  serious,  frequently  difficult  to  cure ;  and  it  is  often  hard  to 
decide  whether  medication  or  Nature  has  effected  a  cure.  Our 
duty  is,  however,  always  to  endeavor  to  relieve  the  patient  no 
matter  how  trifling  her  ailment  may  appear  to  be. 

SALIVATION  OR  PTYALISM  OF  PREGNANCY 

This  is  not  a  common  affection,  but  it  is  sometimes  very  trouble- 
some and  distressing.     It  is  most  common  during  the  early  months, 
but  it  may  continue  until  the  end  of  pregnancy.     The  chief  symp- 
192 


DENTAL   CARTES    AND    TOOTHACHE  193 

torn  is  a  constant  dribblinf^  of  saliva  flurins  both  day  and  night. 
The  saliva  is  generally  changed  in  character,  bcung  more  watc^ry. 
The  digestion  may  be  impaired  through  the  diminution  of  the 
ptyalin. 

Treatment. — Laxatives.  The  most  efficient  are  probably  salines 
or  cathartic  mineral  waters,  such  as  the  Hunyadi  Janos.  Any  of 
the  astringent  mouth  washes  may  be  used,  such  as  solutions  of 
tannin  or  sulphate  of  zinc. 

IJ  Extract!  belladonnae  j  gr.  three  times  a  day. 

3    Pilula?  atropine  jh-^  gr.  twice  or  three  times  a  day. 

King  recommends  the  following  gargle : 

3   Sodii  boracis  glycerini 3  ii ; 

Aquse  Rosse 3  vi. 

Use  as  a  gargle  three  times  a  day. 

Belladonna  or  atropine  sometimes  causes  a  peculiar  dry  con- 
dition of  the  mouth  which  is  more  objectionable  to  the  patient  than 
the  excessive  secretion  of  the  saliva. 

Tonics  such  as  strychnine,  arsenic,  and  iron,  with  a  generous  diet 
sometimes  do  much  good.  Iron  should  be  used  with  care,  how- 
ever, if  the  stomach  is  in  an  irritable  condition,  as  it  frequently  is. 
In  a  patient  of  mine,  confined  last  August,  profuse  ptyalism  com- 
menced about  three  weeks  after  conception  and  persisted  through- 
out pregnancy  in  spite  of  treatment  by  laxatives,  mouth-washes, 
atropine,  and  tonics.  Atropine  diminished  the  flow  of  saliva, 
but  caused  such  an  unpleasant  sensation  that  the  patient  soon  re- 
fused to  take  it.  After  labor  the  ptyalism  still  continued  for  three 
weeks,  diminished  during  the  fourth  week,  and  ceased  entirely  in 
the  fifth  week. 

DENTAL  CARIES  AND  TOOTHACHE 

Caries  of  the  teeth  is  somewhat  common  during  pregnancy. 
Dental  operations  of  a  serious  nature  are  not  advisable  on  account 
of  the  danger  of  inducing  abortion  through  shock.  The  treatment 
of  the  decaying  tooth  should,  as  a  rule,  be  temporary  in  character. 
For  those  who  show  a  tendency  toward  dental  caries  prescribe  the 
following : 

5t  Syrupi  calcis  lactophosphati,  3  i,  three  times  a  day.  If  the 
pain  of  toothache  is  very  severe  it  may  be  advisable  to  administer 


194  DISEASES    OF   PREGNANCY 

morphine  by  mouth  or  hypodermically,  but  it  is  better  to  avoid  it 
if  possible.     For  toothache  with  a  neuralgic  element  prescribe : 

5  Fluidi  extracti  gelsemii  gtt.  iii-v,  three  times  a  day  until 
slight  ptosis  occurs. 

External  applications  to  face  may  be  made,  such  as  Linimen- 
tum  belladonnae,  Linimentum  aconiti,  Linimentum  chloroformi, 
Linimentum  opii. 

DERANGEMENT  OF  THE  STOMACH 

.  The  worst  form  of  this  is  the  so-called  uncontrollable  vomiting. 

A  Typical  Case. — Mrs.  C,  married  at  twenty-seven.  Had  always  been 
healthy.  Became  pregnant  three  months  after  marriage.  In  the  second 
month  had  retching  and  vomiting,  which  grew  worse  in  the  third  month. 
Became  rapidly  emaciated.  Mouth  dry  and  parched,  tongue  red  and  glist- 
ening, breath  offensive.  After  various  medicines  had  been  administered, 
local  cervical  applications  of  silver  nitrate  and  tincture  of  iodine  were 
made.  Slight  improvement  followed  for  a  short  time.  In  a  week  she  again 
commenced  to  fail  and  rapidly  grew  worse.  There  was  almost  constant 
retching  and  frequent  vomiting  of  greenish-colored  mucus,  sometimes 
streaked  with  blood.  The  gums  became  swollen  and  the  teeth  were 
covered  with  sordes.  The  face  became  so  much  pinched  and  her  expres- 
sion was  so  much  changed  that  her  acquaintances  could  hardly  recognize 
her.  A  beautiful,  healthy,  and  happy  girl  had  become  transformed,  in 
a  few  months,  to  a  haggard,  distressed-looking,  wrinkled  old  woman.  I 
was  called  to  see  her  in  the  country  with  a  view  of  inducing  abortion  in 
the  fifth  month.  It  was  too  late.  She  was  dying  when  I  reached  her.  I 
may  add  that  I  think  this  patient  was  skilfully  treated,  but  she  and  her 
husband  (a  physician)  were  so  anxious  to  have  no  interference  with  the 
pregnancy  that  the  last  resort  (the  emptying  of  the  uterus)  was  delayed 
too  long. 

Symptoms. — Nausea  and  vomiting,  usually  commencing  in  the 
second  month,  accompanied  by  emaciation  and  weakness,  are  the 
chief  symptoms.  In  time  nothing  but  bile-stained  and  bloody 
mucus  comes  from  the  stomach.  The  hps  are  cracked ;  the  teeth 
are  covered  with  sordes  ;  the  tongue  is  fiery  red  and  ghstening ;  the 
urine  is  scanty  and  contains  albumin  and  casts.  The  temperature 
is  generally  elevated,  especially  when  the  end  is  near.  The  skin, 
especially  of  the  face,  becomes  dry,  harsh,  and  wrinkled.  There  is 
a  foul  odor  from  breath,  and  finally  delirium  and  coma.  It  is 
strange,  as  pointed  out  by  Spiegelberg,  Reynolds,  and  others,  that 
vomiting  of  pregnancy  rarely  results  in  abortion,  although  this 


DERANGEMENT    OF    Till-:    STOMACH  195 

accident  is  frequently  induced  by  severe  vomiting"  due  to  aeciden- 
tal  gastric  disturbances. 

Treatment. — Regulate  the  diet.  In  some  cases,  during  the 
early  stage,  it  may  be  well  to  give  the  stomach  an  absolute  rest  for 
one,  two,  or  more  days,  the  patient  taking  only  water.  Sometimes 
nutrient  enemata  are  administered  at  the  same  time,  but  in  a  large 
proportion  of  cases  they  are  not  well  borne. 

Enemata  of  salt  solution  or  artificial  serum  generally  produce 
more  satisfactory  results  than  the  nutrient  enemata.  They  are 
better  borne,  dilute  the  toxins  which  are  usually  present,  furnish 
the  needed  liquids  for  the  body,  and  effect  a  true  lavage  of  the 
blood  (Condamin).  The  best  plan  is  to  inject  as  high  as  possible 
10  to  12  ounces  of  the  salt  solution  or  the  artificial  serum,  and 
repeat  often  enough  to  use  4  pints  in  twenty-four  hours.  When 
the  rectmn  is  intolerant  a  few  drops  of  laudanum  should  be  added 
to  each  enema.  If  the  rectum  still  rebels  subcutaneous  injections 
should  be  administered.  The  stomach  should  be  kept  absolutely 
empty  for  seven  to  fourteen  days. 

In  milder  cases,  when  the  stomach  is  not  altogether  intoler- 
ant, small  pieces  of  ice  may  be  sucked.  Frequently  hot  water  will 
have  a  better  effect.  Effervescent  drinks,  such  as  carbonic  acid 
water  or  champagne,  may  be  tolerated  by  the  stomach  when  plain 
waters  are  not.  Sometimes  it  is  well  for  patients  to  take  a  small 
meal  before  getting  out  of  bed — e.  g.,  a  small  cup  of  coffee  and  a 
biscuit.  Or  the  patient  may  be  wakened  between  midnight  and 
early  morning  and  eat  a  small  meal,  after  which  the  lights  may 
be  at  once  extinguished  and  she  may  have  another  sleep. 

Give  liquid  diet,  in  small  quantities  frequently  repeated,  in 
preference  to  sohds,  the  order  of  selection  as  follows :  Buttermilk, 
kumiss,  milk  with  soda-water,  iced  milk.  Meat  soups,  either  beef 
or  chicken,  carefully  freed  from  grease.  Hot  soups,  however,  are 
sometimes  not  well  borne  on  account  of  their  tendency  to  cause 
flatulence.  Well-cooked  farinaceous  liquids,  such  as  barley  water 
and  rice  water.  Scraped  beef,  lean  and  raw,  alone  or  spread  on 
very  thin  bread,  may  be  tried ;  also,  somatose,  lacto-somatose,  or 
lacto-globulin.  Lavage,  or  washing  out  the  stomach  through  a 
tube,  sometimes  does  good. 

With  reference  to  hygiene,  sexual  intercourse  should  be  pro- 
hibited. In  the  early  stages  it  is  not  well  as  a  rule  to  keep  the 
patient  in  bed,  but  she  should  not  do  much  active  work. 


196  DISEASES    OF    PEEGNANCY 

Among  the  host  of  medicines  proposed  I  shall  mention  the  fol- 
lowing :  Calomel,  1  gr.,  j  every  half  hour  for  four  doses ;  follow  with 
a  seidlitz  powder  or  other  saline  cathartic  if  necessary;  wine  of 
ipecacuanha,  one  drop  in  a  teaspoonful  of  water,  every  fifteen  to 
thirty  minutes.  (I  have  seen  this  stop  nausea  in  a  number  of  cases. 
It  is  more  likely  to  have  a  good  effect  if  given  when  nausea  begins 
and  before  vomiting  has  taken  place.  If  three  or  four  doses  are 
given  without  any  effect  it  is  generally  useless  to  continue  it  any 
longer.)  Chloroform,  two  or  three  drops  in  a  tablespoonful  of  cold 
water,  occasionally;  chloral  hydrat.,  20  to  40  grains  per  enema; 
morphine,  i  grain  hypodermically ;  bismuth  subnit.,  20  grains  be- 
fore meals;  cerium  oxalate,  5  to  10  grains  before  meals;  tinct. 
iodin.,  5  to  10  drops  in  water  three  times  a  day;  liq.  arsenicalis, 
one  drop  in  water  three  times  a  day;  muriate  of  cocaine  (3  per 
cent,  solution),  10  to  20  drops. 

Among  other  remedies  recommended  are  menthol,  orexine, 
potas.  iodid.,  nitric  acid,  phosphoric  acid,  sod.  bicarb.,  creosote, 
naphthol,  salicin. 

Local  Treatment. — Certain  forms  of  local  treatment  are  highly 
favored  by  some  obstetricians.  Among  these  one  of  the  most  com- 
mon is  the  application  of  certain  solutions  to  the  os  uteri.  One  of 
the  oldest  remedies  used  in  this  way  is  nitrate  of  silver  in  solution, 
20  to  30  grains  to  the  ounce;  a  solution  of  cocaine  5  to  10  per 
cent,  may  be  used ;  tincture  of  iodine  has  also  been  used.  Such 
treatment  is  supposed  to  be  especially  useful  when  cervical  ero- 
sions exist.  Such  erosions  should  be  touched  about  once  in  three 
days  with  these  solutions.  Where  there  are  no  erosions  the  solution 
should  be  painted  over  the  vaginal  portion  of  the  cervix  and  also 
in  the  cervical  canal,  taking  care  not  to  make  the  application  too 
high  for  fear  of  inducing  an  abortion. 

Operative  Treatment. — Copeman's  Dilatation  of  the  Cervix. — 
Copeman  practised  dilatation  of  the  cervix  with  the  finger.  Many 
agree  with  Copeman  in  considering  that  such  dilatation  often 
serves  a  good  purpose ;  others,  while  agreeing  with  Copeman,  pre- 
fer to  dilate  with  a  steel  dilator.  Kehrer  thinks  that  tamponing  of 
the  cervical  canal  serves  a  better  purpose  than  dilatation  either 
with  the  finger  or  a  steel  instrument.  He  first  pushes  a  funnel  of 
gauze  into  the  cervical  canal  and  then  packs  with  narrow  strips  of 
the  same,  taking  care  not  to  invade  the  uterine  cavity.  Although 
it  is  true  that  either  of  these  methods  may  in  certain  cases  induce 


DISORDERS    OF    INTESTINES  197 

abortion,  still  we  find  that  in  a  large  proportion  of  cases  such  dila- 
tation produces  no  injury. 

Correction  of  Displacements,  if  Any. — Graily  Hewitt  believes 
that  displacement  of  the  uterus  is  often  the  cause  of  the  disease, 
and  tliat  a  correction  of  the  malposition  will  frequently  effect  a 
cure.  Such  displacement  does  certainly  sometimes  cause  vomit- 
ing diu-ing  pregnancy.  In  all  cases,  therefore,  of  displacement  of 
the  uterus  endeavors  should  be  made  to  correct  it. 

Induction  of  Abortion. — When  all  simple  measures  fail  the  last 
resort  should  bo  the  induction  of  abortion.  It  is  difficult  to  give 
any  fixed  rule  as  to  when  this  operation  should  be  performed.  Each 
case  should  be  studied  very  carefully.  In  some  instances  the 
patients  have  very  serious  symptoms,  which  may  suddenly  disap- 
pear. After  such  disappearance  the  patients  often  pass  through 
the  later  months  of  pregnancy  with  comparative  comfort.  One 
should  make  it  a  rule,  however,  never  under  any  circumstances  to 
perform  such  an  operation  without  a  consultation. 

DISORDERS  OF  INTESTINES 

Constipation. — There  are  many  reasons  why  constipation  during 
pregnancy  should  receive  the  most  careful  treatment.  (See  the 
Hygiene  of  Pregnancy.)  The  ordinary  toxaemia  of  pregnancy, 
which  so  frequently  causes  eclampsia,  is  largely  and  sometimes 
wholly  due  to  constipation. 

Dietetic  Treatment. — One  of  the  most  important  factors  is  the 
free  consumption  of  water.  Many  women  are  unusually  thirsty 
during  pregnancy,  but  the  thirst  may  be  abolished  by  inattention, 
mental  preoccupation,  or  other  causes.  Not  less  than  two  quarts  of 
liciuids  should  be  consumed  during  twenty-four  hours.  Among 
lic{uids  I  should  recommend  first,  all  waters  taken  hot  or  cold,  car- 
bonated or  pure;  buttermilk,  kumiss,  bouillon,  weak  tea  or  coffee. 
In  selecting  solid  foods,  one  should  avoid  those  that  are  concen- 
trated, and  choose  a  good  proportion  of  coarse  grains  and  veg- 
etables. The  following  may  be  included  in  the  diet  lists :  White 
bread,  brown  bread  (both  of  which  should  be  at  least  one  day  old), 
toast,  hominy,  porridge,  potatoes,  turnips,  cabbage,  cucumbers, 
tomatoes,  salads,  cauliflowers,  spinach,  boiled  onions,  string  beans, 
green  corn,  asparagus,  green  peas;  fruits  both  raw  and  cooked — 
especially  apples,  figs,  peaches,  stewed  prunes,  cherries,  grapes, 
grape  fruit,  oranges ;  meat  or  poultry  once  a  day,  fish. 


198  DISEASES    OF    PEEGNANCY 

In  any  case  the  patient  should  avoid  any  food  which  is  found  to 
cause  indigestion.  Milk  frequently  causes  indigestion;  but,  in 
addition  to  this  drawback,  its  residue  in  the  intestinal  canal  is  apt 
to  be  formed  into  hard  or  scybalous  masses  which  do  much  harm, 
especially  to  those  disposed  to  constipation.  It  is  better  in  all 
cases  to  give  definite  rules  in  writing. 

Hygienic  Treatment. — Advise  a  fair  amount  of  exercise,  such  as 
walking  in  the  open  air,  a  reasonable  amount  of  ordinary  house- 
work, etc.  The  patient  should  have  meals  at  regular  times,  eat 
slowly,  masticate  the  food  thoroughly ;  go  regularly  to  the  water- 
closet  at  .stated  times ;  employ,  as  nea  rly  as  possible,  the  ' '  squat- 
ting "  posture  during  defaecation.  The  latter  is,  of  course,  difficult 
with  most  of  our  modern  closets,  which  are  so  constructed  that  the 
patient  when  sitting  can  barely  touch  the  floor  with  her  feet.  Such 
faulty  position  can,  to  a  large  extent,  be  corrected  by  placing 
something  on  the  floor,  from  six  to  twelve  inches  high,  upon  which 
the  feet  may  rest.  If  then  the  patient  crosses  the  hands  on  her 
lap  and  bends  over  she  can  nearly,  or  quite,  assume  the  ''squat- 
ting" posture. 

Medicinal  Treatment. — While  the  aim  should  be  to  depend 
chiefly  on  proper  regulations  as  to  hygiene  and  diet  it  will  be  found 
necessary  to  administer  medicines  in  a  large  proportion  of  cases. 
The  following  rules  may  be  followed :  Be  careful  to  avoid  strong 
purgatives  and  large  doses  of  the  milder  laxatives.  Do  not  choose 
drugs  whose  doses  require  to  be  increased  from  time  to  time,  but 
rather  those  whose  dose  may  be  gradually  diminished.  In  all  in- 
stances study  carefully  the  idiosyncrasies  and  susceptibilities  of 
the  patients.  Do  not  continue  any  one  or  two  drugs  for  a  long 
time.  Many  changes  may  sometimes  be  advisable.  The  follow- 
ing is  a  list  from  which  to  choose :  Calomel,  cascara  sagrada,  aloes 
or  aloin,  rhubarb,  magnesii  sulphas,  sodii  sulphas,  sodii  phosphas, 
soda  tartarata,  potasii  tartras,  saline  mineral  waters,  podophyllin, 
senna,  olive  oil,  castor  oil,  tamarind,  strychnine,  belladonna,  ipecac- 
uanha, enemata,  glycerine  suppositories. 

I  place  calomel  at  the  head  of  the  list  with  some  reluctance 
because  I  do  not  consider  that  it  is  the  best  medicine  for  simple 
uncomplicated  constipation.  Auto-intoxication,  however,  is  so 
generally  associated  with  habitual  constipation  that  a  certain 
amount  of  calomel,  followed  by  mild  laxatives,  will  generally  pro- 
duce good  results. 


ENTEKOPTOSIS    ()I{    (iASTHOPTOSIS  199 

Diarrhoea.— Although  in  the  vast  majority  of  cases  diarrhoea 
may  not  cause  any  alarm,  it  is  well  to  bear  in  mind  the  fact  that  it 
may  induce  abortion.  Severe  diarrhoea  may  occur  without  any 
discoverable  cause.  In  such  cases  the  passages  ai-e  i)rofuse  and  fre- 
quent, and  accompanied  with  tenesmus.  The  patient  becomes 
emaciated  and  exhausted  in  spite  of  careful  treatment.  Hess 
applies  to  such  cases  the  term  intractable  and  reports  a  case  in 
wliich  death  ensued.  In  a  series  of  8,674  pregnancies  in  the  Turin 
Maternity  purely  nervous  diarrhoea  occurred  in  thirty-five  cases. 

Treatment.  To  check  a  sharp  diarrhoea  there  is  generally  noth- 
ing better  than  opium  in  the  form  of  a  pill,  dose  1  gr.,  or  de- 
odorized laudanum,  15  minims  (1  gm.).  The  diarrhoea  may,  how- 
ever, be  due  to,  or  associated  with,  toxaemia,  when  caution  in  the 
use  of  opiates  is  necessary.  Calomel  may  be  given  before,  during, 
or  after  the  administration  of  opiates.  When  there  is  nausea  or 
voniiting  use  the  orchnary  suppository  of  lead  with  opium.  If 
the  diarrhoea  appears  to  be  due  to  nerve  disturbances  give  nerve 
sedatives,  such  as  sodium  bromide  grs  xv  (1  gm.),  three  times  a 
day. 

ENTEROPTOSIS  OR  GASTROPTOSIS 

Glenard,  in  1887,  described  a  downward  displacement  of  the 
stomach  (gastroptosis)  with  usual  displacement  of  the  smaller 
intestine  (enteroptosis),  of  the  large  intestines  (coloptosis),  and 
sometimes  of  the  right  kidney.  The  term  splanchnoptosis  has 
been  applied  to  downward  displacement  of  the  abdominal  viscera. 
These  displacements  are  particularly  interesting  from  an  obstetrical 
point  of  view. 

McPhedran  considers  that  the  condition  is  very  common  in 
patients  presenting  symptoms  of  mal-assimilation  with  or  with- 
out digestive  disturbances,  although  ptosis  of  the  stomach  is  often 
present  in  persons  presenting  no  such  symptoms. 

I  have  seen  several  patients  in  past  years  suffering  from  gas- 
troptosis, who  have  greatly  improved  during  pregnancy. 

Maillart  has  been  studying  this  condition  in  connection  with 
pregnancy  for  years  and  says  he  has  been  frequently  astonished  to 
see  the  change  produced  by  pregnancy  in  emaciated  victims  of 
enteroptosis  and  gastroptosis,  who  became  strikingly  plump.  After 
delivery  the  recumbent  position  tends  to  keep  the  organs  in  place, 
but  relapses  frequently  occur  after  the  woman  rises. 


200  DISEASES    OF    PEEGNANCY 

DISEASES  OF  THE  CIRCULATORY  SYSTEM 

Anaemia. — Without  any  reference  now  to  the  normal  conditions 
of  the  blood  in  pregnancy,  which  have  been  already  discussed,  we 
have  to  recognize  the  fact  that  in  abnormal  conditions  during  preg- 
nancy there  is  frequently  a  decrease  of  the  red  corpuscles  and  with 
it  a  decrease  of  albumin. 

Among  the  most  common  results  of  this  are  mal-assimilation, 
muscular  weakness,  impaired  activity  of  secretory  organs,  in- 
creased nerve  irritability,  attacks  of  faintness,  palpitation,  and 
prsecordial  pain.  The  arterial  tension  is  lowered  and  venous  hy- 
peremia follows. 

It  is  very  difficult  in  some  cases  to  decide  as  to  when  the  anaemia 
of  pregnancy  has  taken  on  a  distinctly  pernicious  form.  As  the 
latter  generally  rises  by  slow  gradations  from  the  former  no  sharp 
line  between  them  can  be  drawn. 

Treatment.  The  treatment  of  anaemia  should  be  largely  pro- 
phylactic and  should  be  undertaken  as  soon  as  the  first  symptoms 
of  the  condition  appear. 

Many  obstetricians,  perhaps  the  majority,  place  the  adminis- 
tration of  iron  in  the  front  rank  of  remedial  measures.  I  believe 
that,  in  the  majority  of  cases,  iron  is  not  well  borne  by  pregnant 
women. 

The  anaemia,  in  a  large  proportion  of  cases,  is  caused  by  some 
form  of  toxaemia,  as  stated  more  fully  hereafter.  Such  being  the 
case,  our  first  efforts  should  be  in  the  direction  of  eliminating  the 
poisonous  products. 

It  is  difficult  to  give  any  definite  rules  as  to  diet.  Sometimes  it 
is  well  for  the  patient  to  take  small  quantities  of  simple  nourish- 
ment at  short  but  regular  intervals,  instead  of  three  large  meals  a 
day  as  in  health.  That  kind  of  simple  food  which,  in  the  past,  has 
agreed  with  the  patient's  stomach  should,  as  a  rule,  be  selected. 
Soups  and  broths  should  generally  be  omitted.  In  many  cases  when 
ordinary  meat,  such  as  beefsteak  and  mutton,  does  not  answer,  a 
little  scraped  raw  or  very  much  underdone  meat  may  be  assimi- 
lated. If  evidences  of  toxaemia,  and  particularly  of  renal  insuffi- 
ciency, do  not  exist,  the  newer  condensed  and  desiccated  powdered 
preparations  of  albumin,  such  as  somatose  and  tropon,  may  be 
found  useful.  Other  albuminoid  food  preparations  are  also  recom- 
mended, such  as  eucasin,  lacto-globuhn,  plasmon,  and  sanose. 


DISEASES    OF    THE    CIHCULATOEY    SYSTEM    201 

Administration  of  Tonics.  I  prefer  such  tonics  as  strychnine, 
zinc,  and  the  vejijetable  bitters,  together  with  some  of  the  soda  or 
lime  compounds ;  some  elixirs,  such  as  those  of  strychnine,  bismuth, 
and  pepsin,  or  the  glycero-phosphates  of  soda  and  hme. 

Varicose  Veins.— Varicose  veins  are  very  common  in  pregnancy 
and  are  found  more  frequently  in  multipartc  than  in  primiparai. 
The  saphena  is  the  vein  first  afTected,  then  its  lateral  branches 
upon  the  inner  side  of  the  thigh  and  leg,  and  occasionally  the  veins 
of  the  vulva.     The  hicmorrhoidal  veins  are  also  frequently  affected. 

Treatment.  We  can  not  cure  varicose  veins,  but  we  should 
undertake  a  certain  line  of  treatment  as  soon  as  we  find  them  pres- 
ent. One  should  have  two  aims  in  view :  1,  To  prevent  the  increase 
of  the  dilatation  and  at  the  same  time  afford  some  relief  to  the 
symptoms  ;  2,  to  guard  against  the  dangers  of  rupture. 

One  should  endeavor  to  accomplish  the  first  aim  by  furnishing 
mechanical  support  of  the  enlarged  veins.  This  is  generally  done 
by  the  use  of  the  elastic  stocking  or  by  an  ordinary  roller  bandage. 
A  well-fitting  stocking  often  affords  a  great  comfort  and  is  fairly 
effective.  It  is  very  important  that  it  be  so  made  as  to  fit  snugly 
but  not  too  tightly ;  and,  as  it  is  apt  to  stretch  and  get  loose,  fre- 
quent changes  are  required.  The  stocking,  with  the  changes  gen- 
erally required,  is  expensive  and  perhaps  not  so  effective  as  a  care- 
fully apphed  roller  bandage.  Some  consider  that  a  flannel  bandage 
is  more  effective. 

Lusk  insists  that  the  patient  should  always  be  provided  with  a 
compress  and  bandage,  which  she  should  be  taught  to  apply  her- 
self in  case  of  a  sudden  and  serious  haemorrhage  in  the  absence  of 
professional  or  other  assistance.  Reynolds  recommends  furnish- 
ing her  with  a  small  pad  of  folded  linen,  to  which  a  strap  and  buckle 
have  been  sewn,  and  that  she  should  be  shown  how  to  apply  it  over 
a  bleeding  point  in  case  of  emergency. 

The  following  soothing  ointment  may  be  used : 

Morphine grs.  v. 

Muriate  of  cocaine "    x. 

Calomel "  xl. 

Vaseline 1  oz. 

Apply  locally  night  and  morning. 

If  there  is  much  itching  a  dram  of  menthol  may  be  added  to 
the  above  (Crockett).     In  cases  where  morphine  and  cocaine  are 


202  DISEASES    OF    PKEGNANCY 

contraindicated  other  simple  ointments  may  be  used,  such  as  that 
of  hamamelis  or  boric  acid.  I  think,  however,  that  the  official 
boric-acid  ointment  and  that  of  Lord  Lister  are  both  too  hard, 
either  from  the  addition  of  wax  or  from  the  high  melting  point  of 
the  paraffin,  and  I  prefer  one  of  those  recommended  by  Martindale 
as  follows : 

Paraffin  (L35°  F.  or  140°  F.) 5  parts. 

Vaseline 10       '' 

Boric  acid 3       " 

Apply  night  and  morning. 

DISEASES  OF  THE  RESPIRATORY  ORGANS 

Certain  diseases  of  the  respiratory  system  during  pregnancy 
cause  a  considerable  amount  of  discomfort.  The  dyspnoea  which 
sometimes  occurs,  when  not  caused  by  heart  disease,  may  be  reflex 
or  may  be  due  to  anaemia.  Bromide  of  soda  and  codeine  some- 
times relieve  the  condition.  The  rules  which  have  already  been 
given  as  to  the  management  of  the  stomach  and  bowels  should  be 
observed,  and  the  patient  should  also  be  directed  to  avoid  every- 
thing in  the  shape  of  excitement  or  overexertion  in  order  to  lessen 
as  much  as  possible  the  demands  made  upon  the  respiratory  organs. 

NERVOUS  DISEASES 

Diseases  of  the  nervous  system  in  a  great  variety  of  forms  are 
extremely  common  during  pregnancy.  In  a  general  way  it  may  be 
stated  that  these  disorders,  usually  functional,  rarely  organic,  are 
generally  caused  by  the  following  conditions :  Hydraemia,  general 
toxaemia,  pressure  of  the  enlarged  uterus. 

Neuralgias. — Neuralgia  may  exist  in  any  of  the  sensory  nerves, 
but  is  especially  common  in  two  situations. 

1.  In  the  region  supplied  by  the  fifth  or  trifacial  nerve. 

2.  In  the  region  supplied  by  the  nerves  arising  in  the  pelvis. 

It  is  better  to  treat  the  various  forms  of  neuralgia  by  external 
applications,  such  as  camphor,  chloroform,  aconite,  or  menthol 
liniments.     I  prefer  the  menthol  liniment  made  as  follows : 

IJ  Menthol 3  parts. 

Chloroform 4       '' 

Ohve  oil 9       " 


NERVOUS    DISEASES  203 

As  far  as  medicine  is  concerned  oiu;  should  endeavor  to  treat 
the  hydriemia  or  general  toxieniia  on  general  principles  by  the  ad- 
ministration of  good  food,  tonics,  and  by  proper  elimination  by 
cathartics,  and  perhaps,  to  some  extent,  by  diaphoretics.  In  ex- 
treme cases  it  may  become  necessary  to  prescribe  such  sedatives 
as  morphia  and  chloral,  but  these  should  be  avoided  if  possible. 
If  the  administration  of  morphine  is  considered  necessary  it  is  bet- 
ter to  give  it  by  hypodermic  injection,  without  letting  the  patient 
know  what  medicine  is  being  used.  Never  on  any  account  let  the 
patient  use  the  hypodermic  needle  herself. 

Insomnia. — Insomnia  is  one  of  the  most  common  and  one  of 
the  most  unfortunate  symptoms  which  can  develop  during  preg- 
nancy, and  we  can  do  but  little  to  improve  matters  apart  from 
general  treatment  without  administering  narcotics.  When  the 
insomnia  has  lasted  long  enough  to  produce  evident  nervous  ex- 
haustion we  must  have  recourse  to  some  of  the  hypnotic  drugs. 
The  bromides  of  potassium  and  sodium  are  probably  most  com- 
monly used,  with,  perhaps,  a  preference  for  the  bromide  of  sodium, 
which  is  thought  to  produce  less  gastric  and  intestinal  irritation. 
Reynolds  thinks  that  if  either  bromide  is  used  it  should  be  given  in 
small  doses  of  from  10  to  20  grains,  repeated  several  times  dur- 
ing the  latter  part  of  the  day,  as,  for  instance,  at  5,  8,  and  10  p.m,. 
rather  than  in  one  dose  at  bedtime.  Trional  or  sulphonal  may 
be  given  in  20-grain  doses  at  bedtime.  The  following  mixture 
is  often  useful  where  there  is  a  marked  nervous  irritability : 

I^  Sod.  Bromid 3  ij ; 

Chloral  Hydrat 3  ij ; 

Tinct.  Hyoscyami 3  ij; 

Aq.  ad 3ij. 

A  teaspoonful  at  9  and  10  p.  m. 

As  a  last  resort  the  administration  of  morphine,  in  a  small  pro- 
portion of  cases,  may  be  necessary. 

Exaggerated  Mental  and  Emotional  Disturbances. — The  mental 
disturbances  which  are  apt  to  occur  during  pregnancy  are  numer- 
ous and  varied.  They  are  sometimes  slight,  sometimes  so  serious 
as  to  result  in  insanity.  Certain  traits  of  an  unpleasant  char- 
acter which  may  develop  are  frequently  the  result  of  a  diseased 
condition,  not  bad  temper.     It  not  unfrequently  happens  that  a 


204  DISEASES    OF    PREGKANCY 

patient  usually  even-tempered  and  good-natured,  becomes  dur- 
ing pregnancy  exceedingly  irritable,  suspicious  and  disagreeable. 
Without  becoming  actually  insane,  she  may  develop  a  desire  to 
avoid  those  who  are  near  and  dear  to  her.  These  unfortunate 
traits  are  apt  to  appear  about  the  middle  of  pregnancy  and 
generally  last  until  pregnancy  has  terminated.  In  such  cases 
one  should  always  think  of  the  possibility  of  the  development  of 
insanity.  A  patient  showing  these  symptoms  requires  the  most 
constant  and  watchful  care.  The  surroundings  should  be  of  the 
most  cheerful  sort  and  every  effort  should  be  made  to  prevent  her 
from  thinking  too  much  of  herself  and.  her  condition.  Sometimes 
it  is  well  to  fully  explain  matters  to  her  and  urge  her  toward 
efforts  of  self-control.  It  is  very  often  better  to-  have  her  served 
by  comparative  strangers  rather  than  by  her  most  intimate  rela- 
tives. This  is  the  kind  of  case  where  the  physician  should  use 
all  his  powers  of  magnetism  in  order  to  acquire  her  confidence  to 
such  an  extent  that  he  may  perform  a  sort  of  faith-cure.  The 
physician  and  attendants  should  make  it  their  chief  aim  to  com- 
fort and  cheer  the  patient,  and  while  they  may  require  at  times 
to  be  dogmatic  and  firm  they  should  at  all  times  be  absolutely 
kind.  The  bromides  in  such  cases  may  be  useful  to  some  extent, 
particularly  when  insomnia  is  also  present,  but  otherwise  hyp- 
notics will  accomplish  little  good. 

Chorea. — Next  to  eclampsia,  among  the  neuroses  of  pregnancy, 
chorea  is  the  most  serious.  It  fortunately  is  not  common.  Spie- 
gelberg  says  that  he  has  seen  it  only  three  times  in  his  large  prac- 
tise. Barnes  could  find  only  56  published  cases,  while  others  say 
that  84  cases  only  have  been  described.  I  am  rather  surprised  at 
such  statistics  from  men  of  large  experience  and  am  inclined  to 
agree  with  Dakin,  who  thinks  that  it  occurs  more  frequently 
than  was  formerly  supposed.  Dakin  saw  3  cases  in  two  years, 
2  fatal,  in  St.  George's  Hospital,  and  1  mild  in  the  General  Lying-in 
Hospital.  It  generally  occurs,  for  the  first  time,  during  the  first 
pregnancy  and  may  or  may  not  recur  in  successive  pregnancies. 
The  first  symptoms  usually  appear  between  the  third  and  fifth 
months,  and  not  uncommonly  at  the  time  of  quickening.  The 
choreic  movements  generally  persist  until  after  delivery,  when  they 
gradually  disappear.  The  clonic  spasms  are  generally  severer 
than  in  children  and  in  certain  cases  soon  lead  to  extreme  exhaus- 
tion, which  may  cause  death  before  or  after  delivery.      Death, 


NERYOITS    DISEASES  205 

when  it  ensues,  may  Ije  due  to  the  exhaustion  or  to  complications. 
The  mortality  is  probably  25  to  30  per  cent. 

Treatment.  The  ordinary  medicines,  or  the  so-called  specifics, 
generally  recommended  for  chorea  appear,  as  a  rule,  to  produce 
but  little  or  no  benefit  (lurin<^  pregnancy.  In  a  large  proportion 
of  cases  arsenic  and  iron  produce  no  good  results.  Probably  the 
best  and  most  efficient  remedies,  in  the  way  of  medicines,  are  nar- 
cotics and  sedatives  given  in  large  doses  with  a  view  of  cutting 
short  and  diminishing  the  severity  of  the  attacks  and  quieting 
reflex  irritability.  In  severe  cases  half  a  grain  of  morphine, 
administered  subcutaneously,  will  do  much  toward  controlling 
the  spasms,  if  it  does  not  cure  them.  Opium  in  large  doses  will 
often  produce  a  similarly  good  effect.  Among  the  other  medicines 
which  may  be  recommended  are  chloroform,  chloral,  bromide  of 
sodium,  and  ordinary  tonics  such  as  quinine,  strychnine,  calumba, 
gentian,  etc.  Professor  Oui  prefers  chloral.  He  says  that  in  one 
serious  case  the  daily  dose  of  a  dram  of  chloral  was  followed  by 
great  improvement  in  five  days,  and  by  complete  recovery  in 
twenty- four  days.  Pinarcl  keeps  the  patient  in  a  continuous  sleep 
with  chloral,  awakening  her  only  for  food,  until  the  choreic  move- 
ments are  markedly  diminished.  A  patient,  under  W.  P.  Caven, 
suffering  from  serious  chorea  of  pregnancy  was  speedily  cured 
(apparently)  by  the  administration  of  chloral.  Berry  Hart  reports 
a  case  of  somewhat  mild  chorea  of  pregnancy,  where  antipyrin  in 
grs.  XV  (1  gm.)  doses  four  times  a  day  administered  for  seventeen 
days  appeared  to  cure  the  patient. 

In  severe  cases  the  induction  of  labor  or  of  abortion  is  clearly 
indicated,  and  unfortunately  these  operations  will  not  always  cure. 
In  extreme  cases  operative  interference  should  not  be  postponed 
until  too  late. 

Some  years  ago  a  patient  afflicted  with  severe  chorea  of  preg- 
nancy came  under  my  charge  in  the  Toronto  General  Hospital, 
having  been  sent  in  by  Dr.  W.  R.  Walters. 

Mrs.  K.,  aged  twenty-two.  I  para.  Five  months  advanced  in  preg- 
nancy. The  patient  was  extremely  ill  with  clonic  spasms  much  more 
severe  than  those  generally  found  in  children  (as  is  very  apt  to  be  the  case 
in  chorea  of  pregnancy).  Acute  mania  soon  supervened.  After  a  consul- 
tation it  was  decided  to  induce  abortion.  This  operation  was  performed 
in  as  gentle  a  manner  as  possible.  There  was  no  improvement  in  the 
condition,  the  severe  clonic  spasms  continued,  and  the  patient  died  from 
exhaustion  in  about  two  days  after. 


206  DISEASES    OE    PEEGNANCY 

I  have  seen  one  case  of  unilateral  chorea  in  a  patient,  also  under 
the  charge  of  Dr.  W.  R.  Walters.  I  saw  her  when  pregnancy  was 
advanced  about  four  months.  The  movements  on  one  side  were 
peculiar,  although  supposed  to  be  choreic.  We  were  not  certain, 
however,  that  there  was  not  an  element  of  hysteria  producing  some 
of  the  erratic  movements.  This  patient  was  watched  carefully, 
went  through  pregnancy  without  any  accident,  and  gave  birth  to 
a  living  child. 

PARALYSIS  OF  PREGNANCY 

Various  forms  of  paralysis  may  complicate  pregnancy.  Among 
these  the  most  common  are :  Hemiplegia,  paraplegia,  facial  paraly- 
sis, paralysis  of  the  nerves  of  special  sense. 

Hemiplegia. — Hemiplegia  may  result  from  cerebral  apoplexy, 
or  possibly  from  thrombosis  from  cerebral  anaemia  with  hydrsemia. 
In  a  large  proportion  of  cases  it  has  no  very  serious  effect  either  on 
pregnancy  or  labor  apart  from  the  inconvenience  which  such  a 
condition  naturally  causes. 

Treatment.  Administer  strychnine  and  other  tonics  and  employ 
perhaps  faradization  of  the  affected  limbs. 

Paraplegia  may  be  caused  by  pressure  upon  the  pelvic  nerves 
by  the  foetal  head,  or  it  may  be  traumatic  in  origin.  As  a  general 
rule  it  produces  no  bad  effect  either  upon  pregnancy  or  labor. 
Very  frequently  women  so  affected  suffer  much  less  than  other 
women  in  parturition.  Generally,  also,  involution  of  the  uterus 
takes  place  in  the  ordinary  way,  while  lactation  is  in  all  respects 
normal. 

Facial  paralysis  is  said  to  occur  occasionally  in  pregnancy. 
Its  cause  is  not  clear,  although  it  is  supposed  to  be  due  to  anaemia 
and  hydrsemia. 

Paralysis  of  the  nerves  of  special  sense  is  not  uncommon  and 
may  result  in  such  conditions  as  amaurosis  or  deafness.  It  is 
generally  understood  that  amaurosis,  either  partial  or  complete, 
is  commonly  due  to  renal  disease.  It  is  stated,  however,  that  in 
certain  instances  the  blindness  is  entirely  due  to  an  anaemic  state 
of  the  retina,  which,  as  a  rule,  affects  both  eyes.  Deafness  is  not 
so  easy  to  explain,  as  in  many  instances  the  causes  can  not  be  dis- 
covered or  even  conjectured. 

The  paralysis,  whatever  be  its  nature  or  cause,  generally  dis- 
appears after  parturition. 


DISEASES    OF   THE    SKIN  207 

Muscular  Cramps. — Many  women  during  pregnancy  suffer 
much  from  frequent  attackij  of  muscular  cramps  in  the  thighs  and 
legs.  These  cramps  usually  come  on  at  night  and  often  cause  much 
suffering.  They  are  directly  due  to  pressure  on  certain  nerves  and 
can  not,  therefore,  be  cured  during  pregnancy. 

Fotheringham  thinks  that  these  cramps  are  more  commonly 
exactly  analogous  to  the  cramps  occurring  in  the  athlete,  after 
overexertion,  or  in  the  leg  of  one  who  has  had  phlebitis  say  after 
typhoid  or  childbirth.  The  muscle  being  "  waterlogged  "  by  im- 
peded venous  return  (and  the  lymphatic  return  is  usually  affected 
at  the  same  time  and  by  the  same  cause),  is  irritated  by  the  long 
retention  in  it  of  waste  matters,  which  are  specially  abundant  in 
the  blood  during  pregnancy,  and  when  the  few  hours  of  inactivity 
in  bed  have  deprived  the  muscles  of  the  massage  given  them  by 
their  own  contractions  as  the  patient  moves  about,  the  amount  of 
retained  waste  matter  becomes  sufficient  to  irritate  both  sensory 
and  motor  nerve  terminations  in  the  muscles  to  the  point  of  elicit- 
ing cramps.  The  firm  contraction  and  cramping  kneads  the  mus- 
cles and  to  some  extent  empties  them  of  their  irritant. 

The  cramps  may  be  ameliorated  in  many  cases  by  general  mas- 
sage administered  just  before  bedtime,  or  by  rubbing  with  certain 
applications^  such  as  camphorated  oil  and  menthol  liniment. 

DISEASES  OF  THE  SKIN 

The  following  forms  deserve  special  mention,  although  strictly 
speaking  all  sorts  of  cutaneous  diseases  may  be  met  with. 

Anomalous  Pigmentations. — Ordinary  pigmentations  of  the 
skin,  w^hich  are  normally  present  in  pregnancy,  may  be  greatly  ex- 
aggerated. In  certain  instances  various  portions  of  the  face,  but 
especially  the  brow,  cheeks,  and  chin,  may  be  uniformly  darkened, 
producing  what  is  called  the  mask  of  pregnancy.  In  other  cases 
various  spots  of  pigmentation  occur,  such  as  liver  spots  and  freckles 
(chloasmata  and  ephelides).  These  areas  of  pigmentation  do  not 
extend  into  the  hairy  scalp.  They  are  sometimes  found  on  the 
breasts,  thighs,  and  abdomen.  They  generally  disappear  after  la- 
bor and  as  a  rule  require  no  treatment. 

General  Pruritus. — This  condition  is  not  very  uncommon  and 
often  produces  extreme  suffering,  occasionally  even  resulting  in 
abortion  or  premature  labor. 
15 


208  DISEASES    OF    PREGKANCY 

Treatment.  The  treatment  of  this  form  of  skin  disease  is  some- 
times very  unsatisfactory.  Simple  locahzed  treatment  often  fur- 
nishes great  rehef  and  should  never  be  neglected.  The  best  form 
of  such  treatment  is  the  employment  of  alkaline  baths,  carbonate 
of  soda,  bicarbonate  of  soda,  or  carbonate  of  potassium,  four  to 
eight  ounces  in  an  ordinary  bath.  The  application  of  sedative 
lotions,  such  as  camphor  water,  hamamelis  water,  or  such  liniments 
as  menthol,  aconite,  or  belladonna,  or  solutions  of  carbolic  acid, 
creolin,  or  lysol  1  per  cent,  to  2  per  cent.,  may  produce  good  results. 
In  all  cases  use  laxatives  freely,  especially  if  other  symptoms  of 
general  toxaemia  are  present.  In  some  cases  the  bromides  or  chlo- 
ral, or  both,  may  be  indicated.  Antipyrin  is  often  valuable,  par- 
ticularly if  there  is  an  urticarial  element  in  the  condition.  In  cer- 
tain cases,  where  the  symptoms  are  extremely  severe,  large  doses 
of  opium  or  morphine  may  be  desirable. 

Impetigo  Herpetiformis. — This  is  a  very  peculiar  and  serious 
skin  disease,  which  occasionally  complicates  pregnancy,  and  was 
first  described  by  Hebra.  Small  pustules  appear  on  the  inner  side 
of  the  thighs  and  are  accompanied  by  high  fever  and  great  pros- 
tration. These  pustules  may  also  be  found  in  other  folds  of  the 
body,  especially  near  the  umbilicus,  in  the  axillae,  and  under  the 
mammae.  They  generally  spread  over  the  whole  body.  The 
groups  which  first  appear  soon  become  dried  up  in  the  center,  while 
at  the  same  time  they  extend  peripherally  like  herpes  iris.  Along 
with  the  high  temperature  there  are  chills,  gastric  disturbance  with 
vomiting,  extreme  prostration,  delirium,  followed,  in  the  majority 
of  cases,  by  coma  and  death. 

Treatment.  Give  cathartics  to  a  limited  extent,  stimulants, 
nourishing  food,  and  employ  the  same  sort  of  soothing  treatment 
that  was  recommended  for  general  pruritus. 

Herpes  Gestationis. — This  is  a  pecuHar  neurotic  affection  of  the 
skin,  first,  I  think,  described  by  Bulkley,  somewhat  similar  to  im- 
petigo herpetiformis,  although  much  less  dangerous.  It  also  be- 
gins with  clusters  of  vesicles,  generally  on  the  extremities,  which 
spread  more  or  less  over  the  body.  The  eruption  takes  the  nature 
of  pemphigus  and  erythema  and  is  described  by  Borland  as  show- 
ing on  different  portions  of  the  body,  papules,  vesicles,  and  bullae. 

Treatment  is  similar  to  that  of  impetigo  herpetiformis. 

Purpura  Haemorrhagica. — This  disease  occasionally  complicates 
pregnancy  and  is  similar  to  that  form  which  occurs  during  the  non- 


DISEASES    OF    THE    SKIN  209 

pregnant  state.  When  occurring  in  pregnancy,  however,  it  is  apt 
to  run  a  very  rapid  course  to  a  fatal  termination.  The  mother's 
death  is  generally  due  to  exhaustion,  post-partum  haemorrhage,  or 
sepsis,  and  is  nearly  always  preceded  by  premature  expulsion  of 
the  ovum. 


CHAPTER  XI 
DISEASES  OF  PREGNANCY  (Continued) 

PROLAPSE  OF  THE  UTERUS 

This  condition  is  not  unknown  during  pregnancy,  but  when 
present  it  is  probable  that  it  existed  previous  to  conception.  The 
prolapse  may  be  produced  during  pregnancy  by  a  shock  affecting 
the  whole  body,  or  possibly  through  a  violent  action  of  the  abdom- 
inal muscles.  There  is  generally  associated  with  it  a  prolapse  of 
one  or  both  vaginal  walls,  and  it  will  be  more  convenient  to  speak 
of  the  condition  as  prolapse  of  the  uterus  and  vagina. 

The  condition  is  more  frequent  in  multiparse.  The  prolapse, 
which  is  found  early  in  pregnancy,  disappears  with  the  ascent  of 
the  uterus,  which  usually  takes  place.  In  exceptional  cases  there 
may  be  a  marked  procidentia  causing  a  part  or  the  whole  of  the 
uterus  to  be  extruded  from  the  vagina,  but  procidentia  uteri  is 
frequently  simulated  by  a  marked  hypertrophy  of  the  cervix.  It 
is  important  that  such  hypertrophy  should  not  be  mistaken  for 
prolapsus  of  the  uterus  and  vagina,  because  any  efforts  to  lift  up 
such  a  hypertrophied  cervix  might  lead  to  evil  results.  In  down- 
ward displacements  of  the  uterus  and  vagina  the  course  of  events, 
according  to  Spiegelberg,  is  usually  as  follows :  1.  The  prolapse  dis- 
appears with  the  increase  in  size  and  the  rising  up  of  the  uterus,  at 
most  some  descent  of  the  vagina  only  persisting.  2.  Or  it  may  be 
that  the  uterus,  lying  with  its  cervix  wholly  or  partially  outside 
the  vulva,  with  its  body  in  the  pelvic  cavity,  is  by  injudicious  prac- 
tise neglected,  and  allowed  to  remain  down  until  it  has  grown 
so  large  that  it  can  not  pass  through  the  pelvic  brim.  This  is 
especially  apt  to  occur  when  retroversion  is  associated  with  the  pro- 
lapse. Under  such  circumstances  incarceration  may  occur,  caus- 
ing abortion,  peritonitis,  etc.  3.  In  rare  cases  the  greater  part 
of  a  prolapsed  uterus  may  pass  entirely  out  of  the  pelvis,  and 
unless  artificial  or  spontaneous  reposition  takes  place  pregnancy 
will  be  prematurely  terminated. 
210 


ANTEVERSION  AND  ANTEFLEXION  OF  UTERUS    211 

The- prolapse  of  the  vaginal  walls  always  produces  traction  upon 
the  bladder  and  rectum  and  may  offer  an  impediment  to  delivery 
during  labor. 

Treatment. — Fortunately,  in  the  majority  of  instances,  spon- 
taneous reposition  or  ascent  of  the  prolapsed  uterus  will 
take  place  about  the '  fourth  or  fifth  month.  If  it  does  not, 
then  abortion  is  to  be  feared.  Rest  in  the  recumbent  position 
should  be  tried,  the  bowels  kept  freely  open,  and  the  bladder 
as  nearly  empty  as  possible.  When  necessary,  the  prolapsed 
uterus  and  vagina  should  be  lifted  up  and  should  be  retained 
in  position  by  a  medicated  tampon  of  cotton-wool  held  in  posi- 
tion by  a  perineal  bandage.  According  to  Spiegelberg,  a  fresh 
tampon  should  be  inserted  every  morning  and  removed  at  night, 
or  if  such  a  procedure  is  too  irksome,  a  simple  gutta-percha  ring 
may  be  substituted.  He  prefers  the  tampon,  however,  because  the 
ring  irritates  the  vagina  and  the  portio  vaginalis.  It  may  be 
pushed  down  to  such  an  extent  that  a  perineal  bandage  is  also  re- 
quired. In  some  cases  of  incarceration  it  may  be  difficult,  or  im- 
possible, to  lift  up  the  uterus.  In  such  cases  the  patient  should 
be  put  under  an  ansesthetic,  the  bladder  emptied,  and  the  uterus 
lifted  up.  Sometimes  the  parts  are  so  swollen  that  this  can  not  be 
done  at  once;  under  such  circumstances  the  attempt  should  be 
renewed  at  intervals,  while  superficial  scarifications  of  the  lips  of 
the  OS  and  warm  fomentations  may  be  used  to  reduce  the  swelling. 
In  extreme  cases  it  may  become  necessary  to  empty  the  uterus. 

ANTEVERSION  AND  ANTEFLEXION  OF  THE  UTERUS 

The  increased  weight  of  the  uterus,  especially  in  its  upper  por- 
tion, early  in  pregnancy,  is  apt  to  produce  some  increase  in  normal 
anteflexion  and  anteversion.  A  certain  amount  of  inconvenience 
or  pain  is  so  common  as  to  be  considered  one  of  the  early  signs  of 
pregnancy.  The  pressure  of  the  fundus  on  the  bladder  and  the 
cervix  upon  the  rectum  is  apt  to  produce  a  certain  amount  of 
irritability.  Frequent  and  painful  urination  and  excessive  vomit- 
ing may  occur.  These  displacements  are  generally  rectified  by  the 
ascent  of  the  uterus  into  the  abdominal  cavity. 

Treatment. — Replace  the  uterus  in  its  proper  position  and  keep 
the  patient  in  bed  for  a  time,  introducing  a  pessary  if  necessary. 

In  the  latter  part  of  pregnancy  anteversion  and  anteflexion 


212  DISEASES    OF    PEEGNANCY 

sometimes  produce  the  so-called  pendulous  abdomen.  The  an- 
terior wall  of  the  body  of  the  uterus  may  sink  in  such  a  way  that 
its  lower  portion  forms  a  large  pouch  hanging  down  in  front  of  the 
anterior  wall  of  the  pelvis  while  the  cervix  is  still  in  the  pelvic  brim.. 
The  chief  troubles  produced  by  a  pendulous  abdomen  are  irrita- 
ble bladder,  difficult  defaecation,  pain  due  to  the  stretching  of  the 
abdominal  skin,  excoriation  where  reflexion  exists,  and  oedema  of 
the  lower  portion  of  the  abdominal  walls.  The  proper  treatment 
for  this  condition  is  the  application  of  some  form  of  abdominal 
bandage  during  the  latter  months  of  pregnancy  and  also  during 
labor. 

RETROFLEXION  AND  RETROVERSION 

Retroversion  is  perhaps  the  most  frequent  and  by  far  the  most 
serious  condition  which  can  exist  in  the  gravid  uterus,  and  with 
retroversion  there  is  generally  some  retroflexion.  The  distinction 
is,  in  a  sense,  unimportant  from  a  practical  point  of  view,  and  I 
shall  generally,  in  speaking  of  the  condition,  use  the  word  retro- 
version with  the  understanding  that  there  is  also  some  retroflexion. 

In  the  great  majority  of  cases  the  displacement  existed  before 
conception,  but  it  is  sometimes  caused  by  a  fall  or  other  accident 
during  pregnancy.  This  displacement  soon  becomes  aggravated 
by  the  gradual  enlargement  of  the  uterus.  There  is  generally  a 
partial  prolapse  which  makes  matters  worse.  Early  in  pregnancy 
the  growing  uterus,  and  especially  the  fundus,  presses  upon  the 
surrounding  parts.  Probably,  in  the  majority  of  cases,  as  the 
uterus  enlarges,  it  rights  itself  spontaneously  and  thus  rises  from 
the  hollow  of  the  sacrum  into  the  abdomen. 

Unfortunately,  this  spontaneous  rectification  does  not  always 
take  place;  the  displacement  becomes  aggravated  and  the  uterus 
often  becomes  more  retroverted,  causing  the  cervix  to  be  tilted 
upward  in  such  a  way  that  it  stretches  the  anterior  vaginal  wall 
and  urethra  and  presses  upon  the  bladder  wall;  at  the  same  time 
the  displaced  fundus  presses  upon  the  rectum.  About  the  end  of 
the  third  month,  when  the  uterus  has  become  considerably  en- 
larged, the  fundus  may  be  kept  under  the  sacral  promontory  be- 
cause the  antero-posterior  diameter  of  the  pelvic  brim  is  less  than 
that  of  the  pelvic  cavity.  Thus  we  have  produced  that  very 
serious  condition  which  is  known  as  incarceration  of  the  retro- 
verted gravid  uterus.     While  the  fundus  is  retained  in  the  hollow 


KETROFLEXION"    AND    RETROVERSION  213 

of  the  sacrum  the  cervix  is  i)Us1i(m1  more  and  more  forward  and  up- 
ward until  it  causes  retention  of  urine. 

S3miptoms. — These  are  irritability  of  the  bladder  with  frequent 
micturition,  occasional  retention  of  urine,  a  sense  of  fulness  in  the 
pelvis,  pains  in  the  sacrum  generally  passing  down  the  thighs, 
difficult  and  painful  defecation,  together  with  more  or  less  aggra- 
vation of  some  or  all  ofthe  ordinary  reflex  symptoms  associated 
with  pregnancy.  In  connection  with  these  symptoms  a  tenesmus 
sometimes  exists,  which  is  almost  intolerable,  and  straining  efforts 
in  connection  with  this  tenesmus  greatly  increase  the  agony.     By 


Fig.  112. — Incarceration  of  Retroflexed  Pregnant  Uterus  (Swytzer). 

far  the  most  serious  symptoms,  however,  in  the  great  majority  of 
cases  are  those  connected  with  the  bladder.  It  may  be  that  the 
retention  of  urine,  before  referred  to,  is  not  complete;  urine  con- 
tinually dribbles  to  a  certain  extent  or  is  partially  voided  either 
voluntarily  or  involuntarily  in  such  a  way  that  the  bladder  be- 
comes enormously  distended  even  while  a  certain  amount  of  urine 
is  passed  every  day.  Cystitis,  in  connection  with  this  condi- 
tion, may  greatly  aggravate  matters.  Fortunately  rupture  of  the 
bladder  is  extremely  rare,  although  such  an  occurrence  has  been 
reported.  The  urine  may  be  dammed  back  so  that  it  accumulates 
in  the  pelvis,  or  even  in  the  substance  of  the  kidneys,  and  a  septic 
or  ursemic  poisoning  may  be  produced  not  uncommonly  causing 


214  DISEASES    OF    PEEGNANCY 

death.  Peritonitis  has  also  been  described  as  a  very  rare  cause  of 
death. 

If  the  patient  is  not  properly  treated,  abortion,  incarceration  of 
the  uterus,  sloughing  of  the  bladder  from  pressure,  the  formation 
of  a  fistula,  or  other  serious  results  may  follow. 

Diagnosis. — It  is  not  usually  difficult  to  make  a  diagnosis  of  a 
retroflexed  or  retroverted  gravid  uterus,  before  or  after  it  has  be- 
come incarcerated.  The  symptoms  mentioned  above — namely,  a 
sense  of  fulness  in  the  pelvis,  frequent  micturition,  pain  in  defse- 
cation,  pain  in  the  sacrum  and  thighs,  and  exaggeration  of  vari- 
ous reflex  symptoms — should  lead  one  to  suspect  a  displacement. 
On  making  a  vaginal  examination  one  can  generally  detect  that 
the  fundus  is  thrown  backward  into  the  hollow  of  the  sacrum  and 
the  cervix  is  pushed  forward  and  upward  against  the  bladder.  It 
is  well  to  remember,  however,  that  the  various  subjective  and  ob- 
jective signs  pointing  to  retroversion  may  be  produced  by  such 
causes  as  ectopic  gestation,  fibroma  of  the  posterior  wall  of  the 
uterus,  small  ovarian  tumor,  an  accumulation  of  faecal  matter  in  the 
rectum,  or  anything  in  Douglas's  pouch  which  pushes  the  uterus 
forward  against  the  symphysis  and  causes  retention  of  urine.     I 

was  mistaken  in  the  following  case : 

/ 

Mrs.  C,  aged  thirty.  IV  para.  About  three  months  pregnant.  Sud- 
denly seized  with  a  very  severe  pain  causing  her  to  fall  and  become 
unconscious.  Slight  uterine  haemorrhage.  Mass  detected  in  pelvic 
cavity.  Unable  to  locate  cervix  uteri,  suspected  ectopic  gestation 
with  rupture  into  the  broad  ligament.  Called  Dr.  J.  F.  W.  Ross  in  con- 
sultation. After  careful  examination  under  an  anaesthetic  Dr.  Ross 
expressed  the  opinion  that  there  was  incarceration  of  a  gravid  retro- 
verted uterus.  Without  going  into  further  detail,  I  may  say  that  about 
twenty  hours  afterward  abortion  occurred,  after  which  all  serious  symp- 
toms subsided. 

In  another  case  I  was  for  a  time  much  puzzled. 

Mrs.  S.,  aged  thirty-three.  V  para.  Supposed  to  be  about  three 
months  advanced  in  pregnancy.  Suddenly  seized  with  very  severe  pelvic 
pains.  Found  that  there  had  been  before  much  irritability  of  the  bladder 
and  rectum.  I  at  first  thought  there  was  retroversion  of  a  gravid  uterus 
which  I  attempted  to  reduce.  Was  unable  to  do  so,  and,  for  a  time, 
thought  I  detected  something  which  was  either  a  fibroid  tumor  of  the 
posterior  wall  of  the  uterus,  or  a  small  ovarian  tumor  pressing  against 
the  uterus  and  forcing  it  forward.     After  getting  an  assistant  to  anses- 


RETROFLEXION    AND    RETROVERSION  215 

thetize  the  patient,  I  was  able  to  push  the  fundus  upward  and  then  dis- 
covered that  I  had  nothing  but  a  retroversion  to  deal  with.  I  placed  a 
pad  of  sheep's  wool  under  the  fundus  and  kept  the  patient  quiet  in  bed 
with  the  hope  that  no  evil  results  would  follow.  Two  days  afterward, 
however,  an  abortion  oc(!urrcd. 

Treatment. — Empty  the  rectum  by  enemata  and  catheterize 
the  patient,  using  a  soft,  flexible  male  catheter.  Remember  that 
the  urethra  is  apt  to  be  much  distorted,  the  meatus  generally 
pulled  ujj  behind  the  base  of  the  bladder  and  the  urethra  may  be 
pressed  very  firmly  against  the  symphysis ;  the  point  of  the  cathe- 
ter, therefore,  should  be  directed  close  up  behind  the  symphysis. 
Even  after  having  passed  the  catheter  into  the  bladder  it  is  not 
always  easy  to  withdraw  all  the  urine.  First,  pass  the  catheter 
as  far  as  it  will  go,  then  when  the  urine  has  ceased  to  flow  draw 
it  gradually  forward  and  repeat  if  necessary,  at  the  same  time 
making  external  pressure.  In  some  cases  the  stream  may  be 
obstructed  by  blood  clot,  mucus,  or  detached  mucous  membrane. 
Where  any  such  condition  is  suspected  a  stream  of  warm  borated 
water  may  be  injected  into  the  bladder.  It  may  be  impossible 
to  pass  the  catheter  into  the  bladder ;  under  such  circumstances 
aspirate. 

After  the  bladder  has  been  emptied  efforts  should  be  made  to 
replace  the  uterus,  chiefly  by  pushing  the  body  upward.  Diffi- 
culties may  arise  from  two  causes;  in  the  first  place  adhesions, 
especially  at  or  near  the  fundus  uteri,  may  exist,  or  secondly,  the 
difficulty  may  arise  from  the  swelling  of  the  parts  in  the  pelvis. 
Such  swelling  may  gradually,  to  some  extent  at  least,  subside  after 
the  bladder  is  emptied ;  on  this  account  it  is  not  well  to  push  the 
attempt  at  reduction  too  abruptly.  It  is  often  better  to  keep  the 
woman  perfectly  quiet  in  a  semiprone  position,  and,  as  recom- 
mended by  Barnes,  to  give  a  subcutaneous  injection  of  morphia, 
empty  the  bowel  by  enema  and  introduce  a  Barnes's  bag  into  the 
rectum.  In  one  case  in  Robert  Barnes's  hands,  at  the  London 
Hospital,  this  plan  failed,  but  in  two  others  at  St.  George's  it  com- 
pletely succeeded.  Playfair  also  has  replaced  the  uterus  by  this 
procedure. 

If  this  method  fails  taxis  may  be  again  tried  after  some  hours. 
Anaesthetize  the  patient,  place  her  in  a  semiprone  position,  pass 
one  or  two  fingers  up  the  rectum  and  place  the  tip  or  tips  of  the 
fingers  on  the  right  side  of  the  body  of  the  uterus ;  then  press 


216  DISEASES    OF    PEEGNANCY 

steadily,  not  directly  upward  but  sidewise  toward  the  left  ilium,  in 
order  to  release  the  uterus  from  the  overarching  promontory. 

Barnes  has  found  that  when  the'  uterus  is  thus  pushed  over  to 
the  side  the  fundus  finds  room  in  the  retreating  excavation  at  the 
side  of  the  promontory,  in  consequence  of  which  it  will  rise  for- 
ward with  httle  difficulty,  sometimes  even  with  a  spring.  Some- 
times, while  pressing  on  the  fundus  one  may  use  traction  on  the 
cervix  in  the  opposite  direction  with  or  without  vulsellum  forceps. 
If  recognized  early,  such  cases  have  been  reheved  by  rigorously 
maintaining  for  a  couple  of  days  the  semiprone  posture  on  a  couch 
and  in  bed,  the  knee-chest  posture  being  adopted  for  fifteen  or 
twenty  minutes  every  two  or  three  hours,  and  air  admitted  to  the 
vagina  by  retracting  or  elevating  the  perinseum  with  the  finger,  a 
procedure  of  which  a  nurse  of  ordinary  intelligence  is  capable. 

Induction  of  Abortion. — When  these  efforts  fail  and  urgent 
symptoms  persist  it  may  be  necessary  to  induce  abortion.  This 
may  be  done  in  the  old-fashioned  way  of  introducing  a  sound  into 
the  uterus  and  puncturing  the  amniotic  sac.  This  at  once  reduces 
the  volume  of  the  uterus,  and  taxis  tried  again  after  a  few  hours 
may  be  successful.  After  the  uterus  is  replaced  one  may  complete 
the  abortion  by  more  modern  methods.  Sometimes,  however,  the 
OS  uteri  is  so  high  up  that  it  is  not  accessible ;  when  such  is  the  case 
it  becomes  necessary  to  tap  the  uterus  through  the  posterior  wall 
with  an  aspirator  trocar.  In  doing  this  the  finger  of  the  left  hand, 
applied  within  the  vagina  or  rectum,  feels  the  most  bulging  part 
of  the  uterus,  and  the  trocar,  guided  by  it,  is  pushed  perpendic- 
ularly into  the  uterus.  It  may  be  necessary  also,  sometimes,  to 
puncture  both  the  bladder  and  the  uterus  with  the  aspirator  trocar. 

In  some  cases  when  the  symptoms  are  not  urgent  it  may  be  wise 
not  to  make  any  great  effort  at  reduction  at  once,  but  keep  the 
patient  quiet  and  the  bladder  and  rectum  empty.  Efforts  at  re- 
duction may  be  renewed  at  various  intervals. 

After  Treatment.^ — It  is  very  important,  after  reduction,  to 
prevent  the  uterus  from  falling  back  again  into  tlie  faulty  position. 
I  know  of  no  better  way  of  preventing  this  than  the  introduction  of 
a  suitable  Hodge  pessary.  The  pessary  may  be  removed  in  a  few 
weeks  when  the  increased  size  of  the  uterus  will  prevent  the  fundus 
from  dropping  back  into  the  hollow  of  the  sacrum. 


EETROFLEXION    AND    RETROVERSION  217 


INCOMPLETE  RETROVERSION  OR  INCOMPLETE  RETROFLEXION 

In  some  cases  the  backward  displacement  is  only  partially 
rectified,  and  we  have  incomplete  retroversion  or  retroflexion.  The 
greater  portion  of  the  uterus  passes  up  into  the  abdomen,  but  a 
small  portion  remains  within  the  pelvis  beneath  the  promontory  of 
the  sacrum.  In  explaining  such  a  condition  Spiegelberg  says  that 
the  anterior  wall  of  the  uterus,  which  is  the  least  affected  by  the 
pressure  of  the  neighboring  organs,  rises  into  the  great  pelvis  and 
grows  into  the  abdominal  cavity,  thus  forming  a  secondary  pouch 
in  which  the  great  mass  of  the  foetus  lies  while  the  posterior  wall 
remains  in  the  pelvis.  He  calls  this  a  retroflexion  during  the 
second  half  of  pregnancy  and  labor,  or  a  sacciform  dilatation  of 
the  posterior  uterine  wall.  Although,  as  a  rule,  the  larger  abdomi- 
nal part  of  the  uterus  at  last  draws  up  the  pelvic  part  with  it  and 
thus  completes  reposition,  this  may  not  be  the  case. 

Symptoms  of  incarceration  may  show  themselves  even  at  a 
late  period  where  this  condition  of  incomplete  retroflexion  is  pres- 
ent; they  may  last  but  a  short  time  or  may  be  followed  by  pre- 
mature labor.  When  parturition  occurs  in  these  cases  the  pelvic 
cavity  is  found  to  be  filled  by  a  diverticulum  of  the  posterior  uter- 
ine wall,  and  this,  as  a  rule,  contains  the  head.  The  cervix  is 
pressed  firmly  against  the  upper  edge  of  the  symphysis  and  does 
not  move  into  the  pelvic  axis,  so  that  the  parturient  canal  does 
not  attain  its  natural  development.  The  bulging  wall  is  greatly 
stretched  downward  and  is  occasionally  broken  through.  In  a 
few  cases  when  the  pains  have  lasted  for  some  time  reposition  has 
occurred  spontaneously,  even  at  this  stage  the  os  uteri  receding 
from  its  former  position  toward  its  pelvic  axis. 

Spiegelberg  goes  on  to  say  that  the  diagnosis  of  this  condition 
will  not  be  difficult  if  a  careful  bimanual  examination  is  made. 
Treatment  during  pregnancy  must  be  mainly  expectant,  since, 
apart  from  frequent  dysuria  and  painful  defsecation,  there  are  no 
symptoms.  Gentle  attempts  at  reposition  should,  however,  even 
then  be  made  at  intervals. 

It  is  well,  as  early  as  possible  during  labor  and  while  the  woman 
is  in  the  genupectoral  position,  to  push  the  pelvic  portion  of  the 
uterus  up  with  the  finger  in  the  rectum,  while  the  abdominal  part 
is  firmly  pushed  forward.  The  reposition  will  sometimes  be  facili- 
tated if,  at  the  same  time,  the  cervix  is  pulled  toward  the  middle 


218  DISEASES    OF    PEEGNANCY 

of  the  pelvis  by  the  accoucheur  or  an  assistant  introducing  the 
fingers  into  it.  Digital  dilatation  of  the  os  favors  the  descent  of 
the  presenting  part  and  the  disappearance  of  the  irregularity. 

HERNIA  OF  THE  UTERUS 

Hernia  of  the  unimpregnated  uterus  is  exceedingly  rare,  and  it 
is  still  more  rare  for  a  dislocated  uterus  to  be  impregnated,  or  for 
a  hernia  of  the  organ  to  take  place  after  conception.  It  is  said, 
however,  that  pregnancy  is  sometimes  seen  in  an  inguinal  hernia, 
and  also  in  a  simple  umbilical  hernia,  and  possibly  also  in  a  femoral 
hernia.  The  most  important  condition  of  this  sort,  from  a  prac- 
tical point  of  view,  is  the  so-called  hernia  ventralis,  in  which  the 
gravid  uterus  passes  forward  between  two  recti  muscles  which  have 
become  separated  after  abdominal  section. 

Treatment. — As  soon  as  the  condition  is  discovered  the  uterus 
should,  if  possible,  be  restored  to  its  normal  position  and  retained 
by  a  truss.  Some  think  that  if  it  can  not  be  replaced  abortion 
should  at  once  be  induced,  because  otherwise  it  will  occur  spon- 
taneously later  under  less  favorable  conditions. 

In  cases  of  ventral  hernia  the  organ  should  be  replaced  and 
relapse  prevented  by  an  abdominal  bandage.  I  have  had  two  pa- 
tients who  suffered  from  this  so-called  ventral  hernia.  A  band- 
age was  kept  applied  during  the  later  months  of  pregnancy  and 
during  labor.  In  each  case  the  labor  was  somewhat  tedious  but 
otherwise  uneventful. 

LEUCORRHCEA 

Leucorrhoea,  which  is  so  common  in  pregnancy,  is  sometimes 
described  as  a  disease  of  the  vagina.  There  are  at  least  two  dis- 
tinct forms  of  leucorrhoea,  one  of  which  may  be  called  cervical  and 
the  other  vaginal. 

Cervical  leucorrhcea  frequently,  or  perhaps  generally,  depends 
on  simple  catarrh,  but  it  may  be  due  to  a  deeper-seated  inflamma- 
tion of  the  cervix.  There  may  be  associated  with  it  erosion  and 
perhaps  ulceration.  In  most  cases  the  inflammation  of  the  cervix 
precedes  pregnancy. 

Vaginal  leucorrhoea  is  much  more  common  during  pregnancy, 
even  although  in  a  large  proportion  of  cases  it  may  not  have  existed 
prior  to  conception.     The  secretion  is  frequently  very  copious, 


LEUCORRHCEA  219 

sometimes  thin  and  milky,  sometimes  thick  and  creamy,  sometimes 
purulent,  sometimes  purulo-sanguineous ;  the  latter  two  forms — 
that  is,  the  purulent  and  semipurulent — are  generally  due  to  gonor- 
rhoeal  infection.  The  hypertrophy  of  the  papilla;,  which  is  found 
to  a  certain  extent  in  all  cases  of  pregnancy,  may  become  very 
marked.  There  may  be  a  great  development  of  fungi,  forming 
whitish  or  yellowish-gray  patches  on  a  red  ground,  especially  at 
the  lower  portion  and  at  the  entrance  of  the  vagina.  When  very 
copious  the  discharge  sometimes  causes  great  weakness  and  debil- 
ity. In  a  certain  proportion  of  cases  the  vaginal  walls  become 
greatly  hardened  by  the  leucorrhoea,  and  on  account  of  the  dimin- 
ished elasticity  are  sometimes  torn  during  labor. 

Treatment.— Slight  leucorrhoea  calls  for  no  special  treatment 
except  the  ordinary  efforts  to  maintain  cleanliness.  When  the 
discharge  is  so  profuse  as  to  cause  general  weakness  or  pruritus 
vulvae,  or  both,  careful  treatment  is  required. 

The  simplest  form  of  treatment  is  the  frequent  bathing  of  the 
external  genitals  with  hot  water  and  soap,  or  some  weak  antiseptic 
solution,  such  as  5  per  cent,  boric  acid  or  1  per  cent,  lysol.  If  this 
is  not  sufficient  vaginal  douches  may  be  used.  The  water  used 
should  be  neither  hot  nor  cold,  nor  should  it  exceed,  as  a  rule,  half 
a  pint  in  quantity,  and  great  care  should  be  observed. 

If  a  copious  discharge  is  found,  by  specular  examination,  to 
come  from  the  cervical  canal,  somewhat  strong  applications  may  be 
necessary.  Spiegelberg  recommends  the  single  application  of  an 
active  caustic  (the  red-hot  iron  being  the  best).  Others  advise  the 
application  of  nitrate  of  silver  from  10  to  60  grains  to  the  ounce. 
There  are  two  serious  dangers  connected  with  the  use  of  nitrate  of 
silver.  In  the  first  place  it  may  be  followed  by  more  or  less  hard- 
ening and  stenosis ;  in  the  second  place  it  may  induce  pains.  It  is 
safer  to  make  an  application  of  a  fairly  strong  solution  of  lysol  or 
ichthyol.  A  very  good  way  to  make  the  application  is  to  soak  a 
small  tampon  of  sheep's  wool,  or  absorbent  cotton,  in  a  5  per  cent, 
solution  of  lysol  and  sprinkle  over  it  a  certain  amount  of  boric  acid, 
tannin,  or  powdered  alum  and  place  it  against  the  external  os ;  or 
the  tampon  may  be  medicated  with  a  25  per  cent,  solution  of 
ichthyol  in  glycerine. 


220  DISEASES    OF    PEEGNAKCY 

PRURITUS  VULYiE 

The  intense  itching  of  the  vulva,  which  not  infrequently  exists 
in  pregnancy,  causes  much  suffering  and  sometimes  even  agony. 
The  patient  very  often,  especially  in  first  pregnancies,  dislikes  to 
consult  her  physician  about  such  an  ailment.  Sometimes  the 
physician  is  rather  indifferent  about  a  matter  which  he  considers 
somewhat  trifling  and  does  not  investigate  very  closely  or  treat 
very  carefully.  It  is  the  duty  of  the  physician  to  consider  it  a 
serious  ailment  and  treat  it  as  carefully  as  possible. 

I  have  already  referred  to  another  form  of  pruritus  of  the 
cutaneous  surface,  which  may  be  local  or  general.  See  pages  207 
and  208. 

The  most  common  cause  of  the  pruritus  vulvae  is  leucorrhoea. 
This  is  generally  understood  and  sometimes  leads  the  physician  to 
overlook  the  fact  that  diabetes  is  an  occasional  cause.  Another 
cause  is  the  presence  of  parasites ;  generally  speaking,  the  bacteria 
are  intimately  associated  with,  if  they  are  not  the  cause,  of  the 
leucorrhoea.  Ascarides  in  the  rectum,  in  rare  cases,  produce  the 
condition  and  the  possibility  of  such  a  cause  should  always  be  kept 
in  mind. 

That  rare  form  of  pruritus  which  is  confined  to  the  cutaneous 
surface  without  any  visible  alteration  of  the  skin,  is  probably  a 
pure  neurosis.  Possibly  the  pruritus  vulvae  may  sometimes  be 
neurotic  in  character,  although  this  is  denied  by  some. 

Treatment. — In  a  large  proportion  of  cases  treatment  should 
be  simply  directed  to  the  cure  of  the  leucorrhceal  discharge,  which 
is  the  cause  of  the  itching. 

It  must  be  emphasized  that  the  material  used  for  douches, 
whether  sterile  water  or  medicated  water,  should  be  neither  hot 
nor  cold,  and  not  more  than  a  half-pint  should  be  used  at  a  time. 
This  rule  applies  especially  to  those  cases  where  the  patient  gives 
the  douche  herself.  The  physician  or  nurse  may  use  a  large  amount 
up  to  a  quart  or  two  quarts,  even  more  if  care  is  taken  not  to  use 
too  much  force.  In  fact,  in  using  the  fountain  syringe  one  should 
simply  employ  enough  force  to  make  the  water  enter  the  passage. 
The  reason  for  this  is  evident — the  possibility  that  the  douche  may 
be  forced  into  the  peritoneal  cavity.  Fotheringham  has  found  a 
lotion  of,  say,  one  level  teaspoonful  of  sugar  of  lead  to  a  quart  of 
tepid  water  most  useful  in  such  cases. 


PAINFUL    MAMMARY    GLANDS  221 

A  simple  ointment  containing  cocaine  1  per  cent,  or  2  per  cent, 
may  also  be  tried. 

If  after  a  time  no  improvement  follows  and  the  physician  still 
attributes  the  pruritus  to  the  irritating  discharge,  he  should  con- 
sider that  certain  organisms  are  present  which  should  be  removed. 
As  it  is  difficult,  or  impossible,  to  remove  them  altogether  by  douch- 
ing, it  may  be  necessary  to  adopt  some  procedure  which  will  stretch 
the  vaginal  walls  sufficiently  to  properly  open  out  the  folds.  For 
this  purpose  some  use  bichloride  of  mercury.  I  prefer  a  5  to  10 
per  cent,  solution  of  lysol,  because  it  is  a  good  germicide,  non-irri- 
tating, soapy  in  character,  and  does  not  cause  any  hardening  of 
the  vaginal  walls.  A  fair-sized  tampon,  soaked  in  the  lysol  solu- 
tion, may  be  seized  with  ordinary  dressing  forceps  and  pushed 
along  the  vaginal  tract  with  or  without  the  speculum.  One  may 
introduce  a  Sims  bivalve,  or  Ferguson's  speculum  as  far  as  the 
vault  of  the  vagina,  then  introduce  the  medicated  tampon  and 
gradually  withdraw  the  speculum  while  the  tampon  is  retained  in 
position.  After  this  he  should  hold  the  labia  apart  and  puff  on  a 
powder  to  the  mucous  membrane  with  an  insufflator.  Herman  says 
the  best  powders  are  dermatol  (a  trade  name  of  gallate  of  bismuth) 
and  boric  acid. 

The  presence  of  ascarides  in  the  rectum  would  of  course  call  for 
proper  treatment.  When  the  pruritus  is  cutaneous  it  is  usually 
either  general  or  confined  to  the  abdominal  walls.  Relief  may 
often  be  obtained  by  prolonged  bathing  in  hot  solution  of  bicar- 
bonate of  soda,  or  by  keeping  the  skin  constantly  covered  with  a 
solution  of  acetate  of  lead,  one  dram  to  the  quart,  or  a  solution 
of  carbolic  acid,  one  ounce  to  a  quart,  or  by  inunctions  with  car- 
bolized  vaseline,  one  dram  to  two  ounces. 

PAINFUL    MAMMARY    GLANDS 

Among  the  most  ordinary  signs  of  pregnancy  are  pain  and 
swelling  of  the  breasts.  There  is  generally  some  secretion  of  milk. 
These  conditions  are  probably  simply  exaggerations  of  similar 
conditions  found  in  women  who  are  not  pregnant,  especially  in 
connection  with  menstruation.  The  increase  is  chiefly  in  the 
glandular  tissue,  although  there  may  be  also  some  slight  increase 
of  the  connective  tissue  and  fat.  In  extreme  cases,  when  there 
is  great  increase  of  the  gland  tissue,  there  is  found  a  knotty  feeling 


222  DISEASES    OF    PEEGNANCY 

and  considerable  pain  radiating  from  the  nipple.  The  condition 
is  not  often  sufficiently  serious  to  call  for  any  active  treatment. 
The  administration  of  saline  cathartics  is,  however,  generally  in- 
dicated, and  sedative  applications,  such  as  solutions  of  belladonna 
or  ordinary  evaporating  lotions,  may  be  of  service.  Sometimes, 
when  the  glands  are  greatly  swollen  and  very  tender,  the  Snively 
breast-binder,  neatly  applied,  affords  great  relief.  The  pain  is 
often  of  a  neuralgic  character. 

MYOFIBROMATA  WITH  PREGNANCY 

Hoffmeier  tells  us  that  fibroid  diseases  of  the  uterus  have  no 
direct  influence  in  causing  sterility.  Skene  tells  us  that  fibromata 
of  the  uterus  cause  sterility  in  the  great  majority  of  instances. 
Skene's  statement  is  probably  correct.  In  order  to  simplify  the 
matter  I  shall  refer  to  the  three  ordinary  varieties — submucous, 
interstitial,  and  subperitoneal. 

In  the  submucous  variety  of  myofibromata  pregnancy  is  exceed- 
ingly rare.  When  it  does  occur  under  such  circumstances  early,  or 
fairly  early,  abortion  probably  always  occurs.  We  may,  therefore, 
for  practical  purposes  leave  this  variety  out  of  the  question. 

Interstitial  myofibromata  do  not  always  cause  sterility.  They 
are  especially  dangerous  when  the  tumors  are  connected  wholly, 
or  in  part,  with  the  middle  layer  of  the  muscular  coat  of  the  uter- 
ine wall.  When  large,  in  this  position,  they  generally  prevent  the 
patients  from  going  to  full  term.  The  patients  either  miscarry  or 
die  from  secondary  infections.  Under  such  circumstances  a  mis- 
carriage is  always  dangerous.  When  the  patient  miscarries,  say 
in  the  fourth  or  fifth  month,  the  haemorrhage  is  apt  to  be  very  pro- 
fuse; the  cervix  is  frequently  slow  in  dilating.  It  is  sometimes 
exceedingly  difficult  to  empty  the  uterus  on  account  of  its  mal- 
position. 

Subperitoneal  fibromata  are  less  apt  to  cause  sterility,  less  apt 
to  cause  miscarriage,  and  less  apt  to  interfere  with  labor.  Par- 
ticularly is  this  the  case  when  they  are  situated  in  the  upper  part 
of  the  uterus.  This  is  the  class  of  fibroids  which  is  most  frequently 
associated  with  pregnancy.  In  a  large  proportion  of  cases  they  do 
little  or  no  harm. 

One  of  the  most  important  considerations  in  connection  with 
the  presence  of  such  tumors  during  pregnancy  is  that  of  interfer- 


MYOFIBROMATA    WITH    PREGNANCY 


223 


ence  or  non-interference  with  gestation.  As  a  rule  it  is  not  neces- 
sary nor  advisable  to  induce  abortion.  Patients,  under  such  cir- 
cumstances, should,  however,  be  watched  very  carefully.  One  of 
the  chief  dangers  during  the  early  months  is  that  of  incarceration. 
Such  incarceration,  if  not  promptly  relieved,  becomes  dangerous. 
Replacement  of  the  uterus  and  keeping  it  in  good  position  generally 
give  relief  and  allow  the  gestation  to  go  on  to  full  term.     Apart, 


Fig.  113. — Pregnancy  with  Numerous  Myofibromata. 


however,  from  such  incarceration  the  presence  of  neoplasms  may 
aggravate  the  reflex  disturbances  of  early  pregnancy. 

The  labor  is  apt  to  be  more  tedious  although  it  frequently  ends 
normally.  Forceps  are  frequently  required.  Post-partum  haemor- 
rhage is  perhaps  more  likely  to  occur  than  under  normal  circum- 
stances. So  far  as  my  experience  goes,  however,  the  danger  of 
such  an  occurrence  has  been  greatly  exaggerated  by  many  writers. 
In  a  large  proportion  of  cases  there  is  no  special  tendency  toward 
hsemorrhage  after  labor. 

Fibroid  tumors  generally  grow  to  some  extent  during  preg- 
nancy on  account  of  the  increased  blood  supply  to  the  uterus. 
Occasionally  a  tumor  of  this  sort  may  thus  cause  severe  pain. 

Treatment. — I  have  been  somewhat  surprised  to  find  that  in 
the  great  majority  of  cases  of  pregnancy  occurring  in  connec- 
16 


224 


DISEASES    OF    PREGKAKCY 


tion  with  myofibromata  of  the  uterus  no  interference  is  neces- 
sary. It  fortunately  happens  that  the  uterus  looks  after  itself 
fairly  well. 

A  patient,  referred  to  me  not  long  ago  by  Drs.  W.  P.  Caven  and  G. 
Boyd,  caused  us  for  a  time  considerable  anxiety.   Aged  thirty.    Supposed 


Fig.  114. — Pregnancy  with  obstructing  Fibroids. 
(Tor.  Univ.  Museum.) 


to  be  three  months  advanced  in  pregnancy  (this  supposition  was  correct). 
On  examination  the  uterus  was  found  enlarged,  fundus  being  two  inches 
above  the  pubes,  very  hard,  irregular  in  shape,  enlarged  especially  on  the 
left  side.  This  enlargement  thought  not  to  be  a  separate  ectopic  sac. 
Diagnosis,  myofibromata  present,  especially  in  the  front  and  left  side  of 


DISEASES    OE    THE    DECIDUA    AND    OVUM       225 

the  uterus.     We  decided  not  to  interfere.     Patient  went  on  to  full  term ; 
labor  normal;  healthy  child  born. 

Another  patient,  aged  forty,  was  treated  by  Dr.  James  F.  W.  Ross. 
Uterus  enlarged  for  some  time,  the  enlargement  being  due  to  the  presence 
of  fibroid  tumors.  Hysterectomy  contemplated  but  no  operation  per- 
formed. She  became  pregnant  for  the  first  time  after  being  married 
twenty  years.  Dr.  Ross,  after  watching  the  patient  for  some  months, 
decided  not  to  interfere  and  placed  her  under  my  care.  The  laVjor  was 
somewhat  tedious  but  otherwise  uneventful,  except  that  forceps  were 
required  to  comjilete  delivery.     A  healthy  child  born. 

During  the  last  twenty-five  years  there  have  been  only  two 
patients  in  the  Burnside  Lying-in  Hospital  in  whom  the  presence 
of  fibroids  caused  any  special  anxiety  during  pregnancy  or  labor. 

Patient,  aged  thirty,  seen  by  Dr.  Algeron  Temple,  in  the  ninth  month 
of  pregnancy.  He  found  a  large  tumor  completely  filling  the  pelvis. 
Under  chloroform  was  unable  to  pass  the  finger  beyond  the  tumor  so  as 
to  reach  the  os,  nor  could  he  push  the  tumor  upward  out  of  the  way. 
Sent  her  into  the  Burnside  and  made  arrangements  to  perform  Csesarean 
section  during  labor.  Saw  her  shortly  after  labor  commenced  and  found 
the  tumor  had  moved  a  little.  He  waited  and  watched.  The  tumor 
gradually  moved  to  the  right  and  upward  and  passed  out  of  reach.  The 
child's  head  then  became  engaged  in  the  pelvis,  labor  continued  until 
delivery  was  completed  with  the  forceps.  During  the  puerperium  he 
found  a  tumor  larger  than  a  fist  attached  to  the  right  side  of  the  uterus 
close  to  the  cervix.     Patient  made  a  good  recovery. 

In  the  other  case  the  myoma  occupied  part  of  the  pelvis  and 
the  child  could  not  be  dragged  through  the  pelvis.  The  child  was 
dead  and  craniotomy  and  evisceration  were  performed.  Myomec- 
tomy, Caesarean  section,  Porro's  operation,  hysterectomy,  or  em- 
bryotomy may  be  necessary  when  the  myoma  or  myomata  are  so 
large  and  so  situated  as  to  obstruct  and  prevent  delivery. 

In  case  of  miscarriage  one  should  empty  the  uterus  as  quickly 
and  as  thoroughly  as  possible.  This  is  sometimes  a  very  difficult 
matter,  sometimes  impossible  by  the  ordinary  methods.  In  cases 
of  severe  haemorrhage,  plugging  the  uterine  cavity  with  iodoform 
gauze  is  the  most  effectual  plan  of  treatment. 

DISEASES  OF  THE  DECIDUA  AND   OVUM 

Chronic  Inflammation  of  the  Endometrium. — As  a  result  of 
chronic  decidual  endometritis  we  have  thickening  of  the  endome- 


226  DISEASES    OF    PREGNANCY 

trium.  The  decidua  becomes  sclerotic,  the  interglandular  cellular 
tissues  become  fibrous,  and  the  glands  are  more  or  less  atrophied. 

Chronic  Decidual  Endometritis  with  Polypoid  Excrescences. — 
This  variety  of  decidual  inflammation  is  similar  in  nature  to  the 
last  described ;  but  we  have,  in  addition  to  the  irregular  thicken- 
ing, tuberosities,  and  sometimes  polypoid  excrescences,  attached  to 
the  free  surface. 

Catarrhal  Decidual  Endometritis  or  Hydrorrhcea  Gravidarum. 
— This  is  a  subject  of  m^ore  practical  importance  than  the  forms  of 
endometritis  already  mentioned.  The  causes  of  this  peculiar  con- 
dition are  really  not  known,  but  generally  speaking  it  is  easily  rec- 
ognized clinically.  A  thin,  watery  fluid,  resembling  liquor  amnii, 
but  occasionally  containing  blood,  is  discharged.  The  fluid  comes 
from  the  space  between  the  decidua  vera  and  reflexa.  In  some 
cases  the  fluid  runs  away  steadily;  generally,  however,  there  is 
some  obstruction  to  the  flow  which  causes  the  fluid  to  be  retained 
for  a  time  and  discharged  at  intervals  in  gushes.  It  sometimes 
begins  early  in  pregnancy,  but  is  generally  more  abundant  in  the 
later  months. 

This  flow  of  clear  fluid  is  sometimes  mistaken  for  escape  of  the 
liquor  amnii  or  of  a  fluid  which  is  thought  by  some  to  collect  occa- 
sionally between  the  amnion  and  the  chorion. 

PATHOLOGY  OF  CHORION 

HYDATIDIFORM  MOLE   OR  VESICULAR  MOLE 

In  this  peculiar  disease  the  cysts  which  are  formed  are  filled 
with  fluid  containing  mucin  and  albumin.  These  hydatidiform 
vesicles  are  not  true  hydatids.  True  hydatids  may  occur  in  the 
uterus,  but  such  an  occurrence  must  be  exceedingly  rare.  The 
degeneration  generally  commences  before  the  placenta  is  formed. 
In  such  a  case  the  whole  chorion  is  involved.  Sometimes,  how- 
ever, the  degeneration  commences  after  the  placenta  is  formed ;  in 
that  case  the  villi  of  the  placental  portion  only  are  involved,  the 
other  villi  having  become  atrophied.  Under  such  circumstances 
the  foetus  generally  dies ;  but  it  is  possible  to  have  only  a  few  lobes 
of  the  placenta  involved  in  the  degenerative  process  and  a  healthy 
foetus  may  be  found  with  a  hydatidiform  mole.  More  frequently, 
however,  we  find  a  twin  foetus  associated  with  a  vesicular  mole. 


PATHOLOGY    OF    CHORION 


227 


The  diseased  villi  sometimes  pass  into  the  uterine  wall,  acting  like 
the  normal  villi  to  a  certain  extent  by  dii)pinf2;  into  the  uterine 
sinuses,  but  they  sometimes  pass  more  deeply  into  the  uterine  wall 
than  the  normal  villi  and  may  reach  the  peritoneal  surface ;  under 
such  circumstances  the  uterine  wall  becomes  greatly  weakened  or 
replaced  by  a  diseased 
mass. 

The  uterus  grows 
very  rapidly  in  the  ma- 
jority of  cases  and  gen- 
erally becomes  as  large 
during  the  third  month 
as  the  uterus  at  the  fifth 
or  sixth  month  of  preg- 
nancy, and  occasionally 
as  large  as  the  uterus  at 
full  term.  The  causes 
are  unknown.  It  is  sup- 
posed by  some  that  the 
death  of  the  foetus 
causes  the  extra  nutri- 
tion to  go  to  the  cho- 
rion. There  is  probably 
in  all  cases  some  fault  of 
development  in  the  foe- 
tal portion  of  the  ovum, 
but  what  it  is  we  do 
not  know.  As  the  new 
growth  comes  entirely 
from  the  chorionic  villi 

this  form  of  mole  is  always  a  product  of  conception.  This  is 
sometimes  a  matter  of  very  great  importance,  involving,  as  it 
does  in  certain  cases,  evidence  against  the  moral  character  of 
women  not  legitimately  exposed  to  conception.  The  passage  of 
such  a  mole,  however,  does  not  necessarily  imply  a  recent  concep- 
tion, because  the  diseased  mass  may  be  retained  for  some  time 
within  the  uterus. 

Sjnnptoms. — The  first  symptom  generally  observed  is  the  dis- 
charge of  watery  or  bloody  fluid,  the  latter  of  which  is  sometimes 
said  to  resemble  currant  juice.     Another  common  symptom  is 


Fig. 


115. — Hydatidiform    Mole. 
(Tor.    Univ.  Museum.) 


228  DISEASES    OF    PEEGNANCY 

rapid  enlargement  of  the  uterus,  occurring  especially  in  the  third 
or  fourth  month.  In  conjunction  with  these  two  signs  we  fre- 
quently find  portions  of  cysts — that  is,  clusters  of  the  vesicles — 
coming  away  with  the  discharge.  In  this  case  the  latter  is  com- 
pared to  white  currants  floating  in  red  currant  juice.  The  bloody 
discharge  may  be  very  profuse,  greatly  exhausting  the  patient  and 
sometimes  leading  to  a  fatal  result.  The  only  absolute  sign  among 
those  given  is  the  discovery  of  vesicles  in  the  discharged  fluid,  but 
other  signs  are  mentioned,  such  as  absence  of  ballottement,  ab- 
sence of  foetal  pulse,  unusual  hardness  of  the  uterus,  with  a  doughy 
or  boggy  feeling  and  irregular  surface. 

Treatment. — It  is  not  always  necessary  to  make  a  positive 
diagnosis  before  commencing  treatment.  In  a  certain  number  of 
cases  the  uterine  haemorrhage  is  so  copious  that  it  becomes  neces- 
sary to  empty  the  uterus  as  soon  as  possible — that  is  to  say,  we 
have  to  treat  the  patient  as  if  she  were  suffering  from  inevitable 
abortion. 

The  following  rules  for  treatment  are  recommended : 

Empty  uterus,  dilating  cervix  if  necessary. 

Scrape  out  uterine  cavity  with  finger-tip  or  curette. 

Wash  out  uterus. 

Give  ergot  after  uterus  is  emptied. 

Keep  patient  longer  in  bed  than  after  ordinary  abortions. 

Watch  uterus  carefully  during  involution. 

On  account  of  the  weakened  condition  of  the  uterine  walls  it 
is  necessary  to  use  the  utmost  care  in  curetting,  whether  one  em- 
ploys the  finger-tip  or  curette.  Generally  it  is  safer  to  use  the 
finger-tip  gently.  It  is  very  important,  however,  to  get  every 
portion  of  the  growth  removed,  and  one  should  therefore  reach 
every  portion  of  the  uterine  cavity.  It  is  also  well  to  remember 
that  the  process  of  involution,  under  such  circumstances,  is  often 
much  more  tedious  than  after  abortion  or  premature  labor.  The 
uterus,  therefore,  should  be  watched  very  carefully  and  the  patient 
should  be  kept  at  rest  on  her  back  for  a  comparatively  long  time. 

DISEASES  OF  THE  AMNION 
HYDRAMNION,  HYDRAMNIOS,  OR  POLYHYDRAMNIOS 

This  is  a  condition  in  which  there  is  a  marked  increase  of  the 
liquor  amnii  and  the  results  which  follow  are  probably  due  simply 


DISEASES    OF    THE    AMNION  229 

to  the  mechanical  action  of  the  excessive  amount  of  fliiifl.  The 
disease  is  probably  a  disorder  of  the  foetus,  but  beyond  that  we 
know  little  or  nothing  as  to  its  origin.  A  practical  point  in  this 
connection  is  the  fact  that  malformed  foetuses  are  frequently  found 
in  connection  with  hydramnion,  the  conditions  most  common  being 
hydrocephalus,  meningocele,  spina  bifida,  and  talipes. 

S)nnptoms. — The  chief  symptom  is  great  increase  in  the  size  of 
the  uterus.  This  is  not  generally  noticed  until  the  fifth  month. 
After  this  the  uterus  sometimes  increases  very  rapidly  in  size.  It 
becomes  more  rounded  than  normal  and  tends  to  fall  forward,  thus 
causing  a  certain  amount  of  separation  of  the  recti,  resulting  in 
the  so-called  pendulous  belly.  Pronounced  dyspnoea  is  sometimes 
present.  Pressure  upward  may  limit  the  capacity  of  the  stomach 
and  cause  frequent  vomiting,  while  interference  with  the  circula- 
tion causes  considerable  oedema  and  congestion  of  the  lower  pelvic 
viscera.  Sometimes  these  symptoms  grow  more  and  more  serious 
until  the  uterus  empties  itself,  which  it  is  apt  to  do  prematurely. 
As  far  as  the  child  is  concerned  the  most  common  effect  is  that  con- 
nected with  its  position,  or  lie,  the  malpresentations  being  exceed- 
ingly common.  It  is  said  that  rupture  of  the  uterus  sometimes 
happens,  but  I  have  no  immediate  knowledge  of  any  case  of  the  sort. 

In  making  a  differential  diagnosis  from  the  conditions  already 
mentioned  we  have  to  consider  the  abnormal  enlargement,  together 
with  the  shape  and  consistence  of  the  uterus.  If  we  can  feel  the 
movements  of  the  foetal  parts  and  can  hear  the  foetal  heart  we 
should  always  consider  the  possibility  of  pregnancy  with  some  form 
of  tumor.  For  instance,  pregnancy  existing  with  an  oyarian  cyst 
may  be  difficult  of  recognition,  but  if  we  find  uterine  contractions 
of  one  side  of  the  abdomen,  or  in  one  part  of  the  enlargement,  while 
there  are  none  on  the  other  side  or  in  other  parts,  the  true  condi- 
tion may  become  evident. 

Prognosis. — The  prognosis  for  the  mother  is  generally  favor- 
able, although  there  is  a  certain  risk  of  post-partum  haemorrhage. 
The  prognosis  for  the  child,  on  the  other  hand,  is  quite  unfavor- 
able, the  mortahty  being  fully  25  per  cent.  The  high  mortality 
arises  from  the  following  causes :  Malformation  of  the  foetus,  mal- 
presentations, dropsical  affections,  and  prematurity.  It  is  wise, 
as  a  rule,  to  warn  the  friends  as  to  the  dangers  to  the  foetus. 

Treatment. — We  know  of  no  medicine  which  has  the  shghtest 
effect  in  preventing  the  accumulation  of  the  fluid.      Diuretics,  as 


230  DISEASES    OF    PEEGKANCY 

recommended  by  some,  are  worse  than  useless.  Abstention  from 
the  ingestion  of  liquids,  as  sometimes  practised,  is  apt  to  cause  in 
certain  cases  almost  cruel  discomfort  and  produces  no  good  effect. 
The  patient  should  always  wear  a  well-fitting  abdominal  supporter 
and  should  avoid  active  physical  exertion.  One  should  watch  the 
patient  carefully  and  allow  her  to  go  to  full  term  if  possible.  When, 
however,  the  mother's  health  becomes  seriously  impaired,  espe- 
cially through  grave  disturbances  of  the  heart,  the  induction  of 
premature  labor  becomes  advisable  or  absolutely  necessary. 

In  labor  the  membranes  should  be  ruptured,  using  an  ordinary 
silver  probe  or  some  hard  instrument  if  necessary.  It  is  better  to 
have  a  fair  amount  of  dilatation  of  the  cervix  before  rupture  of  the 
membranes.  Frequently  the  membranes  rupture  before  or  soon 
after  the  commencement  of  labor.  The  result  of  this  is  dry  labor, 
which  is  apt  to  be  very  painful  and  tedious  (see  pages  377  to  382). 

Most  obstetricians  prefer  to  puncture  the  membranes  in  the 
interval  of  the  pains  in  order  that  the  waters  may  escape  gradually, 
to  avoid  the  danger  of  a  sudden  gush,  causing  malposition  of  the 
child.  At  the  Rotunda  the  practise  is  to  wait  until  the  os  is  as  far 
dilated  as  is  considered  safe,  then  introduce  the  hand  into  the 
vagina  and  pass  two  fingers  between  the  membranes  and  the  uter- 
ine wall,  then  slip  a  knitting  needle  or  something  of  the  sort  along 
the  fingers  and  puncture  the  membranes  as  high  up  as  possible. 

My  general  plan  of  treatment  may  be  described  as  follows: 
Give  chloral  hydrate  during  the  first  few  hours,  especially  when  the 
patient  is  suffering  much  pain  and  the  cervix  is  undilated.  If  the 
patient  gets  a  certain  amount  of  rest,  and  the  cervix  becomes  par- 
tially or  wholly  dilated,  much  good  has  been  accompUshed.  I  use 
chloroform  a  Httle  earlier  and  more  freely  than  under  ordinary 
circumstances.  After  a  time  the  patient  is  anaesthetized  nearly, 
or  quite,  to  the  surgical  degree,  the  hand  is  carefully  introduced 
into  the  vagina,  the  cervix  is  fully  dilated,  if  necessary  the  mem- 
branes are  punctured  and  the  hand  is  passed  into  the  uterine 
cavity ;  the  wrist  or  arm  then  acts  as  a  plug,  while  the  hand  cor- 
rects the  malpresentation,  if  any  exists.  The  most  common  mal- 
presentation  which  I  have  seen  is  that  of  the  shoulder,  but  if  one 
acts  promptly  turning  is  generally  easy.  The  following  history 
will  illustrate  my  meaning : 

A.  B.,  aged  thirty.  IV  para.  Had  always  been  healthy.  Hydramnios 
first  noticed  in  sixth  month;  was  well  marked  in  the  last  month.     Went 


DISEASES    OF    THE    AMNION  231 

on,  however,  to  full  term ;  punctured  the  membranes ;  waters  came  away- 
more  rapidly  than  I  wished.  By  external  palpation  found  malposition 
of  the  child,  uncertain  as  to  its  nature.  Introduced  hand  and  found  a 
singular  presentation,  practically  a  shoulder  with  the  head  extended. 
Tried  first  to  convert  it  to  a  vertex,  but  only  succeeded  in  making  it  an 
unsatisfactory  kind  of  face  presentation.  Unable  to  flex  the  head  and 
consequently  decided  to  turn.  This  was  accomplished  very  easily. 
Unfortunately,  the  child  was  still-born. 

About  four  years  after,  the  same  patient  again  became  pregnant  and 
hydramnios  also  developed.  Labor  pains  commenced  at  midnight ;  saw 
her  at  6  A.  M.  Was  suffering  much  from  pains  which  were  very  unsatis- 
factory in  their  results.  Gave  chloral,  15  grs.,  every  twenty  minutes  for 
three  doses.  Pains  less  during  the  forenoon  and  she  had  some  sleep. 
4:30  p.  M.,  chloroform  to  the  surgical  degree  by  an  assistant;  hand  intro- 
duced into  the  vagina.  Os  nearly  dilated.  Completed  dilatation,  punc- 
tured the  membranes,  prevented  escape  of  waters  with  the  forearm  acting 
as  a  plug.  Head  not  engaged  but  floating  loosely.  Tried  to  engage  the 
head  in  brim  but  had  considerable  difficulty.  The  occiput  and  back  of 
the  child  directed  toward  the  right  posterior.  By  internal  and  external 
manipulation  moved  occiput  and  back  anteriorly.  Still  had  difficulty. 
Flexed  the  head  well  and  pushed  it  down  into  the  brim,  but  it  would  not 
remain  fixed  because  I  did  not  let  sufficient  water  escape.  While  I  was 
allowing  it  to  escape  I  had  great  difficulty  in  preventing  the  occiput  from 
slipping  to  the  rear.  Finally,  I  was  able  to  put  on  the  forceps  with  the 
occiput  to  the  right  front  and  delivered  a  healthy  child. 

Oligo -hydramnios  is  the  name  given  to  the  condition  in  which 
the  amount  of  amniotic  fluid  is  abnormally  small.  The  condition 
may  continue  throughout  pregnancy,  but  it  is  only  of  importance 
in  the  early  stages  of  foetal  development.  The  amnion  may  be- 
come adherent  to  the  foetus,  and  a  band  thus  formed  may  encircle 
the  foetal  limbs,  causing  intra-uterine  amputation  and  various  other 
deformities. 


CHAPTER  XII 

INTERCURRENT  DISEASES  OF  PREGNANCY 

The  Acute  Infectious  Diseases. — It  was  at  one  time  thought  that 
pregnancy  and  the  puerperal  state  prevented  a  woman  from  con- 
tracting certain  diseases.  There  is  probably  no  foundation  for  any 
such  belief.  The  acute  infectious  diseases  of  pregnancy  affect  very 
seriously  both  foetus  and  mother.  In  a  large  proportion  of  cases 
they  cause  the  death  of  the  foetus.  The  question  naturally  arises, 
Is  the  death  of  the  foetus  caused  by  the  poison  or  by  the  high  tem- 
perature in  the  mother?  By  both;  but  the  high  temperature  is 
probably  the  more  serious  factor.  A  temperature  in  the  mother 
of  104°,  or  higher,  is  exceedingly  dangerous  to  the  foetus,  though 
cases  have  occurred  in  which  the  maternal  temperature  reached 
105°  without  causing  the  death  of  the  foetus.  The  mother  may 
have  a  moderate  increase  of  temperature,  say,  100°  to  103°,  for 
some  time,  without  seriously  injuring  the  foetus,  but  when  she  has 
a  temperature  of  104°  for  any  length  of  time  the  foetus  is  likely  to 
die.  The  acute  infectious  diseases  sometimes  set  up  a  hsemorrhagic 
endometritis  which  destroys  the  decidua  and  thus  indirectly  causes 
the  death  of  the  fcetus. 

TYPHOID  OR  ENTERIC  FEVER 

Among  the  various  forms  of  continued  fever  typhoid  or  enteric 
is  that  which  most  frequently  attacks  the  pregnant  woman.  It 
may  do  so  at  any  period  of  pregnancy,  but  is  more  apt  to  do  so 
during  the  early  months.  The  first  symptoms  of  typhoid  fever 
may  appear  during  or  shortly  after  labor.  Under  such  circum- 
stances it  was  formerly  extremely  difficult  to  make  a  differential 
diagnosis  between  typhoid  fever  and  septicaemia,  and  the  tendency 
of  some  practitioners  was  to  give  the  name  typhoid  fever  to  the 
condition  in  cases  where  septicaemia  was  much  more  likely  to  give 
rise  to  the  symptoms  present.  We  should  not  go  to  the  other 
232 


TYPHOID    OR    ENTERIC    FP]VER  233 

extreme,  however,  and  forget  that  fever  following  abortion  or  labor 
may  be  typhoid. 

A  short  time  ago  I  saw  with  Dr.  Alexander  a  case  of  fever  fol- 
lowing abortion.  We  thought  it  was  due  to  septicaemia.  Dr. 
McPhedran,  who  also  saw  her,  thought  it  might  be  typhoid.  A 
marked  Widal  reaction  and  a  blood  test  showing  leucopenia  proved 
that  he  was  probably  right. 

In  1887,  E.  C.  admitted  to  the  Burnside  while  in  labor.  Child  still- 
born. Temperature  shortly  after  labor  106°.  Severe  post-partum  haem- 
orrhage. Death  occurred  on  the  following  day.  Post-mortem  exami- 
nation by  Dr.  W.  H.  B.  Aikens.  No  streptococci  found,  but  typhoid 
bacilli  were  found  in  the  spleen  and  Peyer's  patches  were  ulcerated. 

Dr.  W.  P.  Caven  had  two  cases  of  typhoid  fever  in  the  sixth  montli  of 
pregnancy.  In  one  the  temperature  reached  105°  on  three  successive 
days,  but,  apart  from  these,  was  never  above  103°.  Recovery.  Living 
child  born  three  months  after.  In  the  other  case  patient  had  mild 
fever,  highest  temperature  being  103°.  Recovery.  Living  child  born  at 
full  term. 

Dr.  N.  A.  Powell's  patient,  pregnant  six  months.  High  temperature 
for  ten  days,  highest  being  105°.  Aborted  on  the  seventeenth  day. 
Child  lived  a  few  minutes.  Mother  had  a  good  recovery.  He  had  three 
other  patients  with  typhoid  during  pregnancy;  one  in  the  seventh  month 
aborted  at  the  end  of  the  third  week;  one  in  the  sixth  month  aborted  at 
the  end  of  the  third  week;  one  in  the  third  month  aborted  at  the  end  of 
the  second  week.     The  three  mothers  recovered. 

The  reports  of  other  physicians  in  Toronto  are  pretty  much  of 
the  same  character.  Abortion  occurred  in  the  majority  of  the 
cases,  but  the  mothers  generally  made  good  recoveries.  In  a  large 
proportion  of  mild  cases  the  typhoid  fever  had  apparently  no  effect 
on  mother  or  foetus. 

Statistics  from  various  parts  of  the  world  show  that  abortion 
occurs  in  from  60  to  65  per  cent,  of  the  cases  of  typhoid  fever  in 
pregnancy.  The  results  to  the  mother  appear  to  vary  very  greatly 
in  different  localities,  and  depend,  evidently,  to  a  large  extent  on 
the  malignity  or  benignity  of  the  disease.  In  Toronto  most  of  the 
epidemics  of  typhoid  fever  have  been  of  a  fairly  mild  character. 

Treatment. — There  are  no  specific  drugs  which  are  known  to 
have  any  direct  effect  in  the  cure  of  typhoid  fever.  It  is  well  to 
remember  in  connection  with  treatment  that  a  new  poison  is  added 
to  the  mother's  system  in  addition  to  the  greater  or  less  degree  of 


234     INTERCUREENT    DISEASES    OF    PREGNANCY 

general  toxaemia  which  is  apt  to  be  present.  On  this  account  I 
think  it  well  to  pursue  the  treatment  recommended  for  toxaemia  of 
pregnancy.  I  prefer  calomel  with  mild  salines  during  the  first  ten 
days.  Other  drugs  which  may  be  used  are  salol,  /?-naphthol,  bismuth 
salicylate,  and  creosote.  Otherwise  one  should  treat  symptoms  as 
they  arise,  but  especially  the  high  temperature.  One  should  try 
to  prevent  the  temperature  from  reaching  any  degree  higher  than 
103°.  The  best  method  of  doing  this  is  by  hydrotherapy,  according 
to  the  method  recommended  by  Brand,  or  some  modification  of  it. 
Personally,  I  prefer  cold  sponging  to  the  cold  bath. 

SCARLATINA 

The  period  of  incubation  of  scarlet  fever  may  be  greatly  pro- 
longed. As  Olshausen  tells  us,  a  pregnant  woman  may  become 
infected  and  the  poison  is  likely  to  remain  latent  until  the  comple- 
tion of  labor.  It  appears  as  if  the  condition  of  pregnancy  were 
antagonistic  to  the  evolution  of  scarlet  fever.  The  woman  may 
have  been  infected  weeks,  and  possibly  months,  before  labor 
without  showing  the  ordinary  symptoms.  The  puerperal  state, 
it  is  said,  invites,  intensifies,  and  accelerates  the  evolution  of 
scarlet  fever. 

There  has  been  considerable  confusion  respecting  the  associa- 
tion of  scarlatina  with  other  conditions,  such  as  septicaemia,  in  the 
puerperal  state.  We  may  have  scarlatina  alone,  or  scarlatina  asso- 
ciated with  septic  infection,  or  septicaemia  with  the  so-called  scar- 
latiniform  rash,  but  no  scarlet  fever. 

Most  observers  accept  Olshausen 's  statement  that  four-fifths 
of  all  puerperae  attacked  will  show  symptoms  within  the  first  three 
days  after  labor.  The  throat  complications  are  generally  slight; 
the  eruption  passes  very  rapidly  over  the  whole  body  and  may 
have  a  dark  red  color  instead  of  the  ordinary  bright  scarlet.  There 
is  generally  complete  suppression  of  the  secretion  of  milk  and  also 
of  lochial  discharges  when  the  scarlatina  comes  on  soon  after  labor. 
There  is  generally  a  slight  tenderness  over  the  uterus  for  a  time 
and  pelvic  inflammations  very  frequently  appear. 

Formerly,  the  mortality  was  said  to  be  very  high,  from  40  to 
60  per  cent.  It  is  probable,  however,  that  in  a  large  proportion 
of  the  reported  cases  the  patients  were  suffering  from  puerperal 
infection  with  a  septic  erythema  and  not  from  scarlatina. 


ERYSIPELAS  235 

A  patient  exposed  to  scarlatina  during  labor  or  in  the  puerperal 
state  may  contract  the  specific  disease,  scarlet  fever,  but  she  does 
not  contract  septicaemia  from  this  particular  form  of  exposure. 
If  she  has  a  combination  of  septic  infection  with  scarlet  fever  the 
former  is  due  purely  to  the  introduction  of  certain  germs,  espe- 
cially certain  cocci,  from  without. 

ERYSIPELAS 

Erysipelas  may  occur  at  any  time  during  pregnancy,  labor,  or 
the  puerperal  state,  and  should  always  be  considered  a  very  serious 
complication.  Much  has  been  written  in  the  past  about  the  sim- 
ilarity between  erysipelas  and  septic  infection  both  from  a  bac- 
teriological and  cHnical  standpoint.  I  prefer  to  consider  erysipelas 
from  a  clinical  standpoint.  Practically,  I  think  one  may  consider 
that  erysipelas  and  sepsis,  as  we  usually  find  it  in  the  puerperal 
state,  are  separate  and  distinct  diseases.  A  woman  may  pass 
through  labor  while  suffering  from  erysipelas  without  any  evil 
results  excepting  those  directly  due  to  the  erysipelas.  Erysipelas 
of  the  genital  tract,  however,  is  much  more  serious  than  erysipelas 
of  the  extremities  or  of  the  face. 

The  symptoms  of  the  disease  during  pregnancy  are  similar  to 
those  found  in  the  non-pregnant  woman.  The  following  reports 
illustrate  fairly  well  the  various  results  that  may  follow: 

Dr.  Smith's  patient.  Six  months  pregnant.  Injured  her  knee.  Ery- 
sipelas developed  in  the  thigh  eight  days  afterwards  and  was  followed 
by  a  large  abscess  burrowing  beneath  the  muscles.  Premature  labor 
occurred  at  seven  and  one-half  months.  The  puerperal  period  was  nor- 
mal and  the  child  survived. 

Dr.  J.  Ford's  patient.  Seventh  pregnancy.  Erysipelas  developed 
about  full  term.  Healthy  child  born  two  days  after.  Lochial  discharge 
and  lacteal  secretions  not  interfered  with.  Disease  lasted  five  days  after 
labor.  Puerperal  convalescence  after  this  normal.  Child  did  well  although 
it  nursed  from  the  breast. 

The  following  case  was  reported  in  the  British  Medical  Journal. 
I  have  no  note  of  the  author's  name : 

Patient,  aged  thirty;  in  the  eighth  month  of  pregnancy  developed 
erysipelas.  Healthy  child  born  three  days  after.  Was  fed  from  the 
bottle  twenty-one  days.  A  breast-reliever  was  used  to  keep  up  the  milk 
secretion.  Child  put  to  the  breast  after  twenty-one  days.  Highest  tem- 
perature, 103°;  liighest  pulse  rate,  140.     Good  recovery. 


236     INTERCUEEENT    DISEASES    OF    PEEGNANCY 


In  speaking  of  this  case  the  author  asks,  ' '  How  long  after  the 
disappearance  of  erysipelas  is  the  breast  milk  likely  to  be  impure?" 
This  question  I  can  not  answer,  but  I  should  suppose  that  it  is 
quite  safe  to  allow  the  child  to  nurse  from  the  breast  as  soon  as  the 
ordinary  symptoms  of  erysipelas  disappear.  In  Dr.  Ford's  case 
the  child  had  no  nourishment  excepting  that  derived  from  the 
mother's  breast,  even  while  erysipelas  was  present.  Careful  exam- 
ination of  the  milk  generally  shows  that  it  contains  some  patho- 
genic germs,  and  yet 
the  child  in  a  large  pro- 
portion of  cases  thrives 
even  on  such  milk. 

MEASLES 

The  symptoms  of 
measles  occurring  dur- 
ing pregnancy  are  sim- 
ilar to  those  ordinarily 
observed.  Bronchitis 
is  a  serious  complica- 
tion. Incessant  cough, 
with  accompanying 
movements  of  the  ab- 
d  o  m  i  n  a  1  walls,  fre- 
quently induces  abor- 
tion. The  infection 
may  be  transferred 
from  mother  to  child. 

SMALLPOX 


Fig.  116. — Babe  Died  in  Utero  from  Smallpox 
(Tor.  Univ.  Museum.) 


Smallpox  is  a  seri- 
ous complication  of 
pregnancy  and  very 
frequently  causes  the  death  of  the  foetus.  It  is  supposed  by  some 
that  pregnancy  renders  the  mother  especially  liable  to  infection  of 
smallpox.  There  is  nothing  special  to  say  about  symptoms  or  treat- 
ment excepting  that  vaccination  during  pregnancy  should  be  per- 
formed invariably  whenever  smallpox  is  prevalent.  Such  vacci- 
nation is  important  both  in  the  interests  of  the  mother  and  foetus. 


CHOLERA  237 


PNEUMONIA 

Pneumonia  during  pregnancy  is  certainly  a  very  serious  com- 
plication for  both  mother  and  child.  There  is  nothing  special  as 
to  symptomatology.  It  is  probable,  however,  that  heart  failure 
is  more  apt  to  develop'  in  the  pregnant  than  in  the  non-pregnant 
woman. 

Mann  reports  a  case  of  a  woman,  aged  forty-two,  with  typical  pneumonia 
at  eighth  month  of  pregnancy.  The  foetal  heart  sounds  ceased  five  days 
after  the  initial  chill.  Shortly  after  the  crisis  of  the  pneumonia  the  child 
was  delivered  with  the  aid  of  the  forceps.  Child  dead.  Mother  made 
good  recovery. 

Davis  reports  a  case  of  a  young  primi-gravida,  aged  twenty,  who  devel- 
oped pneumonia  when  near  the  end  of  gestation.  A  temperature  of  103° 
F.  rapidly  developed  and  an  acute  pneumonic  process,  catarrhal  in  nature, 
was  found  over  both  lungs.  Although  the  os  was  partly  dilated  no  labor 
pains  were  present.  The  patient's  distress  and  dyspnoea  increased  and 
three  days  after  the  beginning  of  the  pneumonia  the  child  was  expelled 
with  three  or  four  severe  labor  pains.  The  child  was  cyanosed,  had  fever, 
and  after  passing  through  an  attack  of  pneumonia,  recovered.  Although 
the  mother's  urgent  symptoms  were  relieved  temporarily  by  her  labor, 
she  died  from  heart  failure  soon  afterward. 

Treatment  of  pneumonia  complicating  pregnancy  is  similar  to 
that  in  the  non-pregnant  woman.  The  patient  is  not  improved 
by  the  induction  of  abortion.  Cupping  gives  considerable  relief 
in  certain  cases,  as  also  does  the  hypodermic  use  of  strychnine  and 
atropine.  The  prognosis  is  bad,  the  maternal  mortality  being 
nearly  50  per  cent.,  while  the  foetal  mortality  is  probably  over 
50  per  cent. 

CHOLERA 

I  have  had  no  experience  with  cholera  in  pregnancy.  The  fol- 
lowing facts  are  taken  from  the  annual  report  of  the  Hamburg 
State  Infirmary  by  Schultz  : 

The  mortality  of  the  mother  and  the  tendency  to  abortion  are 
greater  the  later  in  pregnancy  the  patient  is  attacked.  Next  to 
smallpox  no  disease  so  surely  provokes  interruption  of  pregnancy. 
It  is  very  deadly  to  the  foetus  at  any  stage.  Labor  is  usually  pro- 
tracted on  account  of  weak  pains ;  flooding  is  not  frequent ;  sep- 
tic infection  is  somewhat  common.  Out  of  115  pregnant  cholera 
patients  the  mortality  was  44  per  cent. 


238     INTEECUERENT    DISEASES    OF    PEEGNANCY 

TETANUS 

Tetanus  is  more  apt  to  occur  during  the  early  than  during  the 
late  months  of  pregnancy.  It  may  develop  after  any  minor  opera- 
tion during  the  first  half  of  pregnancy,  but  especially  where  abor- 
tion has  required  manual  or  instrumental  deliverances.  It  is  more 
common  in  hot  than  in  temperate  climates,  and  in  the  dark-skinned 
than  in  the  Caucasian  races.  It  may  also  develop  during  the  puer- 
peral period,  but  such  an  occurrence  is  exceedingly  rare. 

The  proper  treatment  is  prophylactic.  One  should,  therefore, 
remember  that  pregnant  patients  are  peculiarly  susceptible,  and 
be  exceedingly  careful  in  his  antiseptic  methods  when  performing 
any  operation  or  examination. 

TETANY 

Tetany  is  somewhat  common  in  pregnancy  and  lactation  in 
some  countries.  It  is  characterized  by  tonic  spasm,  beginning  in 
the  muscles  of  the  extremities,  especially  those  of  the  hands. 
Such  spasms  may  frequently  recur  for  brief  periods.  They  are 
painful  in  character  and  not  accompanied  by  loss  of  consciousness. 
The  spasms  may  be  local  or  may  involve  many  different  regions 
of  the  body.  In  the  slighter  attacks  a  numbness  and  tingling  may 
be  felt  in  the  fingers  and  toes,  which  soon  become  fixed  in  the  tonic 
spasm.  The  spasms  may  extend  to  higher  parts  of  the  limbs  and 
become  very  painful. 

The  diagnosis  is  based  on  the  progressive  character  of  the 
attacks,  which  begin  in  the  upper  and  lower  extremities,  and  after 
a  time  intermit,  and  upon  the  absence  of  loss  of  consciousness. 

The  prognosis  is  usually  favorable,  the  complaint  gradually  sub- 
siding after  a  few  months. 

Davis,  in  contrasting  tetanus  with  tetany  in  the  pregnant 
woman,  emphasizes  the  following  points:  In  tetanus  the  spasm 
begins  in  face  or  neck  and  advances  centrifugally  with  opisthotonos. 
In  tetany  the  spasm  begins  in  the  extremity  and  advances  cen- 
tripetally.  In  tetanus  the  spasm  is  constant;  in  tetany  it  is 
intermittent. 

INFLUENZA 

Influenza  is  not  uncommon  during  pregnancy  and  the  puer- 
perium.     In  the  three  serious  epidemics  that  we  have  had  in 


RHEUMATISM  239 

Toronto  since  1890  the  influenza  showed  no  respect  for  either  of 
these  conditions.  In  the  Burnside  a  large  proportion  of  the 
inmates  were  attacked  during  two  epidemics.  The  results  were 
favorable  and  the  mortality  was  nil.  These  good  results  were,  I 
think,  due  to  the  fact  that  the  patients  were  properly  treated. 
Waiting  patients  were  put  to  bed  and  kept  quiet.  Those  attacked 
during  the  puerperium  were  also  kept  quiet  in  bed  until  all  danger 
was  past.  We  were  able  to  avoid  the  two  great  dangers  which 
caused  the  serious  results  outside,  viz.,  fighting  the  disease  a  day 
or  two  too  long  before  going  to  bed,  and  getting  out  of  bed  and 
going  to  work  a  day  or  two  too  soon.  Some  obstetricians  have 
noted  more  serious  results  with  abortion  or  premature  labor  in  a 
large  proportion  of  cases.  In  many  cases  the  interruption  of 
pregnancy  was  preceded  by  profuse  haemorrhage.  The  effects  of 
the  influenza  vary  to  some  extent,  of  course,  with  the  severity  and 
character  of  the  epidemic. 

MALARIA 

Malaria  is  one  of  the  most  serious  of  the  intercurrent  diseases 
of  pregnancy  and  the  puerperium  in  some  parts  of  Canada,  although 
not  so  common  now  as  it  was  twenty  to  thirty  years  ago.  Shortly 
after  labor  women  appear  to  have  an  increased  liability  to  this 
disease,  which  is  apt  to  appear  about  the  third  or  fourth  day  after 
delivery.  The  important  point  as  to  diagnosis  is  to  decide  between 
malaria  and  septicaemia. 

Treatment. — If  the  patient  has  previously  had  malaria  before 
or  during  pregnancy  a  high  temperature  and  rapid  pulse  during 
the  puerperium  are  likely  to  be  due  to  a  recurrence  of  the  disease 
resulting  from  the  traumatism  of  labor.  One  should,  however, 
under  such  circumstances,  carry  out  the  ordinary  treatment  for 
septicaemia  and  give  in  addition  20  to  30  grains  of  quinine  a  day. 
Some  think  that  the  quinine  accomplishes  almost  as  much  for 
septicaemia  as  it  does  for  malaria  in  certain  cases. 

RHEUMATISM 

Rheumatism  is  not  uncommon  during  both  pregnancy  and  the 
puerperium.     Its  occurrence  after  labor  is  of  more  importance, 
because  it  may  then  be,  and  perhaps  generally  is,  due  to  septicaemia. 
17 


240     INTEECUEEENT    DISEASES    OF    PEEGNANCY 

BRONCHOCELE 

Bronchocele  may  appear  for  the  first  time  during  pregnancy, 
or  one  that  existed  before  may  enlarge  during  pregnancy.  Strain- 
ing during  labor  may  cause  temporary  increase  of  the  swelling  of 
the  thyroid,  but  such  enlargement  usually  subsides,  at  least  to  a 
large  extent,  after  delivery. 

HiEMORRHAGES 

Women  who  have  haemophilia  or  are  liable  to  haemorrhages 
from  any  cause  generally  have  such  liability  increased  during 
pregnancy,  labor,  and  the  puerperium.  Among  the  haemorrhages 
which  are  apt  to  occur  during  pregnancy  are  haemoptysis,  epi- 
staxis,  bleeding  from  stomach  and  rectum,  and  cerebral  haemor- 
rhage. 

LEAD  POISONING 

Lead  poisoning  is  quite  common  during  pregnancy  of  women 
engaged  in  certain  industrial  occupations.  It  induces  abortion  in 
many  cases  by  causing  the  death  of  the  foetus.  Much  may  be 
learned  from  a  book  on  "Dangerous  Trades,"  edited  by  Dr. 
Oliver,  of  Newcastle-upon-Tyne,  regarding  the  dangers  to  which 
pregnant  and  nursing  women  are  exposed  while  working  in  facto- 
ries. He  tells  us,  when  speaking  of  the  employment  of  women  in 
lead  works,  that  the  lead  exercises  an  injurious  influence  upon 
the  reproductive  functions,  especially  of  pregnant  women.  When 
a  white-lead  worker  becomes  pregnant  she  generally  aborts  if  she 
continues  to  follow  her  employment.  If,  as  occasionally  happens, 
she  goes  to  term  the  child  is  generally  born  dead  or  dies  shortly 
after  birth  from  convulsions.  Among  many  reports  he  gives  one 
of  a  woman  who,  after  giving  birth  to  four  children  at  full  term, 
went  into  the  lead  works  for  six  years.  During  this  time  she  had 
nine  miscarriages  in  succession  and  no  living  child. 

MERCURIAL  POISONING 

Mercurial  poisoning  is  apt  to  occur  in  women  engaged  in  such 
industries  as  the  manufacture  of  barometers,  thermometers,  elec- 
trical meters,  incandescent  electric  lamps,  water  gilding,  etc.     The 


FACTORY    EMPLOYMENT  241 

symptoms  are  stomatitis  and  salivation,  destruction  of  teeth, 
muscular  weakness,  tremors,  impairment  of  speech,  physical  dis- 
turbances, and  dysmenorrhoea.  Miscarriage  is  frequent  and  the 
offspring  is  liable  to  be  the  subject  of  rickets  or  scrofula. 

TOBACCO  POISONING 

It  has  been  stated  by  some  that  pregnant  women  who  are 
tobacco  workers  are  apt  to  abort.  It  is  stated  by  others  that  they 
sometimes  suffer  from  loss  of  vision.  Oliver  thinks  such  state- 
ments have  not  been  clearly  proven,  and  expresses  the  opinion 
that  healthy  women  working  in  well-built  and  well-ventilated 
factories  do  not  suffer  materially  from  tobacco  working.  He 
occasionally  meets,  however,  in  the  Newcastle  Dispensary,  female 
tobacco  spinners  who  suffer  from  persistent  headache,  nausea, 
anaemia,  and  muscular  feebleness;  but  he  has  not  observed  that 
miscarriage  is  more  frequent  in  them  than  in  women  engaged  in 
other  occupations. 

FACTORY  EMPLOYMENT,  PREGNANCY,  AND  CHILD-BIRTH 

One  can  not  say  definitely  to  what  extent  house  or  factory  work 
is  dangerous  for  pregnant  women.  A  healthy  woman  can  generally 
do  her  ordinary  work  up  to  the  time  of  the  onset  of  labor  without 
incurring  any  serious  risk.  One  can  speak,  however,  with  con- 
siderable precision  as  to  women  after  child-birth.  They  should  not 
engage  in  house  or  factory  work  for  four,  five,  or  six  weeks  after 
labor.  There  are  definite  laws  regarding  such  things  in  most  of 
European  countries,  as  we  learn  from  one  of  the  articles  by  Miss 
A.  M.  Anderson,  Principal  Lady  Inspector  of  Factories  in  England, 
in  Dr.  Oliver's  book  referred  to  above. 

Belgium. — ''Women  must  not  be  employed  in  industry  within 
four  weeks  after  child-birth." 

Switzerland. — "A  total  absence  from  employment  in  factories 
of  women  during  eight  weeks  before  and  after  child-birth  must  be 
observed,  and  on  their  return  to  work  proof  must  be  tendered  of 
an  absence  since  birth  of  the  child  of  at  least  six  weeks." 

Spain  prohibits  employment  of  women  within  three  weeks  of 
child-birth,  but  also  compels  employers  to  allow  one  hour  at  least 
in  the  ordinary  period  of  employment  (for  which  there  must  be  no 
reduction  in  wages)  to  nursing  mothers  to  nurse  their  infants.    This 


242     INTEECUEEENT    DISEASES    OF    PEEGNANCY 

hour  may  be  divided  into  two  separate  absences,  which  may  be 
chosen  by  the  mother. 

We  have  in  Ontario  a  male  and  a  female  Inspector  of  Fac- 
tories. A  good  many  married  women  are  employed  in  industrial 
occupations  in  Ontario,  chiefly  among  the  ragpickers.  Their  ages 
vary  from  twenty  to  eighty  years,  and  a  number  of  the  younger 
women  can  not  come  to  work  in  the  morning  until  their  children 
have  been  sent  off  to  school.  Their  employers  allow  them  to  make 
up  time  later,  but  not  to  exceed  a  total  of  sixty  hours  per  week. 

Miss  Carlyle,  Female  Government  Inspector  of  Shops  and  Fac- 
tories, is  of  the  opinion  that  there  are  few  nursing  mothers  among 
industrial  workers  and  that  most  nursing  mothers  who  are  com- 
pelled to  work  seek  employment  chiefly  in  households  as  washer- 
women and  not  in  shops  or  factories.  There  are  no  special  reg- 
ulations re  the  employment  of  married  women  in  the  Province  of 
Ontario. 

APPENDICITIS    DURING   PREGNANCY 

Appendicitis  occurs  somewhat  commonly  during  pregnancy. 
Osier  considers  that  appendicitis,  as  a  rule,  is  a  disease  of  young 
persons  and  quotes  Fitz's  statistics,  showing  the  relative  frequency 
of  appendicitis  in  patients  of  all  ages  and  conditions.  The  figures 
show  that  more  than  50  per  cent,  occur  before  the  twentieth  year, 
60  per  cent,  between  the  sixteenth  and  thirtieth  years.  The  dis- 
ease is  also  very  much  more  common  in  males  than  females — 90 
per  cent.,  according  to  Fitz.  From  these  statistics  we  should  infer 
that  only  a  small  proportion  of  women  over  thirty  are  attacked  in 
any  case.  We  should,  therefore,  not  expect  to  see  a  large  number 
of  cases  of  appendicitis  during  pregnancy.  I  am  not  sure  whether 
women  during  pregnancy  are  more  subject  to  attack  than  under 
ordinary  circumstances,  but  they  are  at  least  equally  liable.  I 
rather  agree  with  Marx,  who  says  there  is  reason  to  think  that 
the  congestion  of  the  system  and  the  vicious  condition  of  the 
blood  associated  with  pregnancy  act  as  a  predisposing  cause  of 
appendicitis. 

Varieties. — I  shall  accept  Osier's  statement  that,  for  practical 
purposes,  we  should  recognize  a  catarrhal  and  ulcerative  appen- 
dicitis, at  the  same  time  bearing  in  mind,  however,  the  fact  that 
with  the  ulcerative  form  we  may  have  perforation  or  gangrene,  or 
both.     Beyond  this  I  shall  refer  only  to  diagnosis  and  treatment. 


APPENDICITIS    DURING    PREGNANCY  243 

Diagnosis. — The  question  of  diagnosis  is,  of  course,  exceedingly- 
important.  Obstetricians  have,  I  fear,  been  somewhat  slow  in 
recognizing  or  appreciating  this  fact.  Many  cases,  if  not  the  major- 
ity, even  during  the  last  ten  years,  have  been  almost  certainly 
overlooked,  but  there  has  been  a  great  improvement  in  this  respect 
during  the  last  five  years. 

Pinard  considers  that  an  early  diagnosis  is  usually  possible. 
He  adds  that  all  abdominal  pain  during  pregnancy  should  be  care- 
fully investigated.  If  the  pain  is  not  due  to  uterine  contractions, 
pointing  to  threatening  abortion  or  labor,  the  possibility  of  appen- 
dicitis should  always  be  considered.  It  is  well  to  remember, 
perhaps,  in  this  connection,  that  tenderness  is  more  important 
diagnostic  evidence  than  pain.  The  vomiting  of  appendicitis  is 
entirely  different  from  that  of  the  ordinary  vomiting  of  pregnancy. 
In  the  latter,  as  a  rule,  the  temperature  and  pulse  remain  normal 
and  severe  pain  is  not  present. 

Symptoms. — Pain  and  tenderness  are  generally  the  first  symp- 
toms that  appear;  they  are  found,  usually,  but  by  no  means 
always,  in  the  region  of  the  appendix.  These  pains  are  frequently 
colicky  in  character,  especially  in  catarrhal  and  obstructive  appen- 
dicitis. Fever,  as  indicated  by  high  temperature  and  rapid  pulse, 
is  always,  or  at  least  generally,  present.  Muscular  rigidity  is 
generally  present,  especially  in  the  right  rectus,  but  is  not  so  dis- 
tinct as  in  the  non-pregnant  state.  Other  symptoms,  such  as 
vomiting,  constipation,  diarrhoea,  and  tympanites  may  be  present. 

Treatment. — It  is  not  easy  to  lay  down  definite  rules  as  to  treat- 
ment. A  large  proportion,  probably  70  to  80  per  cent.,  of  patients 
with  acute  appendicitis  recover  under  judicious  medical  treatment. 
Subsequent  attacks,  however,  are  apt  to  occur,  and  it  must  make 
one  at  least  uncomfortable  to  think  that,  after  a  patient  has  passed 
through  two  or  three  or  four  attacks,  she  may  die  from  the  next 
recurrence.  Of  course  one  must  bear  in  mind  the  fact  that  fre- 
quently the  recovery  is  permanent.  Operative  measures  are  nec- 
essary in  certain  cases  under  ordinary  circumstances.  Are  such 
procedures  justifiable  during  pregnancy?     Yes,  certainly. 

Pinard  tells  us  an  inflamed  appendix  requires  speedier  surgical 
relief  in  pregnancy  than  under  other  conditions,  and  the  fact  of 
pregnancy  must  in  no  other  sense  influence  the  operator ;  in  other 
words,  it  is  wrong  to  provoke  abortion  or  induce  premature  labor. 
There  is  a  focus  of  infection  especially  dangerous  in  pregnancy, 


244     INTEECUEEENT    DISEASES    OF    PEEGNANCY 

therefore  it  must  be  removed.  The  conscientious  obstetrician 
must  always  feel  anxious  when  a  patient  during  pregnancy  has  her 
first  attack  of  appendicitis,  especially  when  ' '  stormy  ' '  symptoms 
are  present. 

Medical  Treatment. — Osier  gives  expression  to  his  methods  in 
three  words:  rest,  opium,  and  enemata.  This  is  exactly  the  line 
of  treatment  recommended  by  Alonzo  Clark  and  Fordyce  Barker, 
which  was  generally  carried  out  forty  years  ago.  Many  physicians, 
however,  are  absolutely  opposed  to  the  use  of  opium  in  the  treat- 
ment of  appendicitis,  because  the  tendency  of  the  drug  is  to  inten- 
sify the  intestinal  paralysis  or  paresis  and  increase  the  tympanites, 
thus  favoring  the  development  of  pathogenic  microbes  and  free 
migration  through  the  paretic  intestinal  walls. 

Whatever  our  views  may  be,  I  think  that  the  following  state- 
ments made  by  Senn  should  be  accepted  in  their  entirety:  Lax- 
atives must  never  be  given  if  there  is  any  indication  that  perfora- 
tion has  taken  place.  The  moment  perforation  has  taken  place 
all  influences  must  be  brought  to  bear  to  quiet  intestinal  peristalsis 
and  to  limit  the  escape  of  septic  material  into  the  free  peritoneal 
cavity. 

My  own  line  of  treatment  is  pretty  much  the  same  as  that  for 
the  toxaemia  of  pregnancy,  with  perhaps  the  single  exception  that 
I  attach  much  importance  to  the  use  of  opium  in  the  majority  of 
cases  of  acute  appendicitis.  My  routine  plan  is  about  as  follows : 
Give  first  calomel  followed  by  saline  cathartics,  nothing  being  bet- 
ter than  Epsom  salts.  If  after  the  patient  has  taken  from  two  to 
five  grains  of  calomel  and  two  doses  of  salts  the  bowels  remain 
unmoved,  a  rectal  enema,  not  to  exceed  a  quart  of  soap-suds  con- 
taining two  tablespoonfuls  of  castor  oil  and  one  of  glycerine,  should 
be  administered.  I  consider  that  the  catharsis  is  especially  re- 
quired for  the  pregnant  woman  suffering  from  the  disease,  because 
of  the  natural  tendency  toward  general  toxaemia.  Free  catharsis 
produces  good  results  directly  by  eliminating  poisons  from  the 
neighborhood  of  the  diseased  appendix,  and  this  elimination  indi- 
rectly aids  in  securing  rest  for  the  inflamed  part  and  in  quieting 
the  intestinal  peristalsis.  After  free  catharsis  has  been  established, 
give  opium  if  it  appears  to  be  indicated,  especially  for  severe  pain 
or  if  there  is  any  reason  to  fear  perforation. 

Senn  considers  that  the  best  laxative  is  castor  oil  given  in 
tablespoonful  doses  every  three  hours  until  the  bowels  move  freely. 


APPENDICITIS    DURING    PEEGNANCY  245 

I  understand  that  a  large  number  of  physicians,  especially  in  the 
United  States,  entirely  agree  with  Senn  as  to  the  virtues  of  castor 
oil,  but  some  prefer  to  combine  it  with  olive  oil,  because  the  latter 
makes  a  soothing  application  to  the  inflamed  surface. 

Food. — During  the  acute  stage  little  or  no  food  should  be  given 
by  the  mouth,  but  as  much  water  as  the  patient  naturally  wishes. 
When  there  is  vomiting  water  should  only  be  given  in  the  shape  of 
normal  saline  solutions,  by  the  rectum  or  subcutaneously ;  in  all 
cases  solid  food  and  plain  milk  should  be  withheld.  In  giving  food 
by  the  mouth  choose  from  the  following :  barley  water,  rice  water, 
albumin  water,  whey,  broth,  thin  flour  soups,  etc. 

Surgical  Treatment. — There  is  no  doubt  as  to  the  fact  that  when 
ulcerative  appendicitis  has  given  place  to  perforation  or  a  gan- 
grenous condition,  or  both,  surgical  interference  is  absolutely  nec- 
essary. Unfortunately,  we  are  not  always  able  to  make  our 
diagnosis.  The  uncertainty  which  so  frequently  exists  as  to  exact 
diagnosis  is  responsible  for  many  unnecessary  operations  and  also 
for  many  dangerous  delays. 

I  shall  not  attempt  to  discuss  in  detail  the  many  vexed  ques- 
tions which  have  arisen  as  to  methods  and  time  for  operation.  In 
a  certain  proportion  of  cases  early  operation — that  is,  operation 
within  twenty-four  hours  after  the  attack  of  appendicitis — is  the 
correct  procedure.  The  intermediate  operation  is  required  in  cer- 
tain cases  where  complications  arise,  such,  for  instance,  as  the 
formation  of  an  abscess  and  the  presence  of  progressive  septic 
peritonitis.  The  late  operation  is  frequently  required  when  ab- 
scesses are  found  to  exist  weeks  or  months  after  the  acute  symp- 
toms have  subsided. 

The  operation  during  the  interval  between  attacks,  when  no 
symptom  of  inflammation  of  the  appendix  or  surrounding  parts' is 
present,  is  performed  by  some.  I  have  not  seen  any  cases  where  I 
thought  an  operation  was  necessary  under  such  circumstances 
during  pregnancy.  I  should  hope,  after  an  attack  of  catarrhal 
appendicitis,  to  prevent  the  recurrence  during  pregnancy  especially 
by  the  eliminative  treatment.  Following  are  brief  reports  of  cases 
with  certain  comments. 

C.  K.,  aged  thirty-three.  VI  para.  Attended  by  me  ten  years  ago. 
Three  months'  abortion.  Unusual  amount  of  pain  before  and  during 
abortion;  some  tenderness.  Pain  and  tenderness  over  abdomen  contin- 
ued after  the  uterus  was  emptied.     Patient  seen  by  the  late  Drs.  Strange 


246     INTEECUREENT    DISEASES    OF    PEEGNANCY 

and  McFarlane  in  consultation.  Two  days  after  supposed  completion 
of  abortion  uterus  examined,  curetted  with  finger-tip,  and  washed  out. 
Nothing  found  in  uterus.  No  offensive  discharge.  Two  days  afterward 
patient  got  much  worse.  Swelling  found  in  right  groin,  signs  of  general 
peritonitis.  Patient  died  in  a  few  hours.  Cause,  probably  appendicitis 
with  perforation.  Appendicitis  was  not  suspected  until  about  twenty- 
four  hours  before  death. 

In  this  case  the  patient  probably  had  appendicitis  some  days 
before  abortion,  which,  I  think,  should  have  been  recognized  by  me 
earlier  than  it  was.  I  did  not  at  the  time  attach  sufficient  impor- 
tance to  the  tenderness,  which  is  more  important  than  the  generally 
accompanying  symptom,  pain.  Without  going  into  further  details 
I  may  say  there  were  many  reasons  why  I  should  have  suspected 
appendicitis  rather  than  septicaemia.  Whether  an  earlier  diagnosis 
would  have  enabled  us  to  save  the  patient's  life  I  know  not. 

Pinard,  in  a  paper  recently  published,  quotes  two  cases  of 
appendicitis  complicating  pregnancy,  in  which  an  erroneous  diag- 
nosis was  made  and  a  fatal  termination  ensued.  In  the  one,  a 
patient  at  full  term  was,  during  labor,  seized  with  severe  peritonitic 
symptoms  which  were  attributed  to  rupture  of  the  uterus.  The 
labor  was  terminated  naturally.  On  opening  the  abdomen  a  gan- 
grenous appendix  was  found  and  removed ;  general  peritonitis  was 
present  and  the  patient  died  some  hours  later. 

In  the  other,  a  patient  two  months  pregnant  was  treated  for 
some  days  for  indigestion  with  threatening  miscarriage.  The  pa- 
tient when  seen  presented  all  the  symptoms  of  acute  appendicitis 
and  died  a  few  hours  later. 

As  a  contrast,  however,  he  relates  three  cases  successfully 
treated  by  operation  during  pregnancy. 

Case  I.  Multipara,  aged  twenty-nine.  Six  months  pregnant.  Was 
seized  with  violent  abdominal  pains  and  vomiting.  Rigidity  was  de- 
tected in  the  right  iliac  fossa,  and  per  vaginam  a  mass  was  plainly  felt. 
Appendicitis  was  diagnosed  and,  a  few  days  later,  operation  was  per- 
formed, a  gangrenous  appendix  being  removed.  The  patient  recovered 
rapidly.     Premature  labor  came  on  a  week  later. 

Case  II.  Multipara,  aged  thirty-four.  Pregnant  three  months.  Had 
for  ten  days  been  suffering  from  a  severe  pain  in  the  right  iliac  region, 
with  vomiting  and  pyrexia.  On  admission  to  the  hospital  her  condition 
was  very  grave;  pulse  120,  temperature  102.6°,  abdomen  much  distended 
with  increased  resistance  over  the  right  iliac  region.     A  diagnosis  of 


APPENDICITIS    DURING   PEEGNANCY  247 

appendicitis  complicating  pregnancy  was  at  once  made.     Operation  was 
performed,  appendix  removed.     Rapid  recovery. 

Case  III.  Multipara.  Five  months  pregnant.  Was  seized  with  severe 
abdominal  pain  and  vomiting.  Five  days  later,  on  admission,  she  was 
evidently  suffering  from  intestinal  obstruction.  Per  vaginam  nothing 
could  be  made  out.  Operation  performed,  appendix  was  found  bound 
down  by  a  dense  band  into  the  right  iliac  fossa  and  constricting  the  bowel. 
Appendix  removed.     Patient  recovered. 

Pinard's  conclusions  were  as  follows : 

1.  Appendicitis  may  be  observed  in  pregnant  women,  primip- 
arse  or  multiparse,  at  all  periods  of  gestation. 

2.  During  pregnancy  appendicitis,  though  often  commencing 
insidiously,  has  a  tendency  to  become  of  a  very  grave  type. 

3.  Operative  interference  at  the  earliest  possible  moment  offers 
the  best  chance  of  cure. 

4.  Even  in  cases  apparently  hopeless  operation  sometimes 
saves  life. 

George  A.  Peters  not  long  since  saw  a  patient  after  labor  who 
was  suffering  from  abdominal  pain,  with  high  temperature  and 
rapid  pulse.  Thece  symptoms  existed  to  some  extent  before  labor 
and  were  not  understood.  The  labor  was  premature  and  child  still- 
born. A  few  days  after  labor  a  lump  was  found  in  the  right  side. 
Appendicectomy  performed  about  ten  days  after  labor.  Patient 
made  a  good  recovery.  In  this  case,  as  in  my  own,  the  diagnosis 
was  made  at  a  somewhat  late  period,  but  fortunately  in  time  to 
admit  of  an  operation  with  a  very  happy  result. 

Another  interesting  thing  to  consider  in  connection  with  this 
case  is  the  relationship  between  the  uterus  and  the  abscess.  Af- 
ter the  fourth  month  of  pregnancy  the  side  of  the  uterus  gen- 
erally forms  a  part  of  the  wall  of  the  appendiceal  abscess.  Under 
such  circumstances,  during  and  after  labor,  the  contracting  uterus 
may  pull  on  the  abscess  and  injure  its  wall  in  such  a  way  as  to  per- 
mit pus  to  pass  into  the  abdominal  cavity  and  set  up  progressive 
or  general  peritonitis.  On  the  other  hand,  irritation  from  the  ap- 
pendicitis may  cause  abortion.  The  hyperpyrexia  itself,  through 
its  fatal  effect  on  the  ovum,  may  also  produce  abortion.  Munde 
thought,  on  account  of  these  possible  or  probable  effects,  immediate 
appendicectomy  should  be  performed  in  cases  of  appendicitis, 
even  after  the  onset  of  labor.  Marx,  however,  in  such  cases,  pre- 
fers to  deliver  the  woman  at  the  beginning  of  labor  by  a  manual 


248     INTEECUEEENT    DISEASES    OF    PEEGNANCY 

dilatation  of  the  cervix,  and  version  or  forceps,  and  immediately 
thereafter  tampon  the  utero-vaginal  tract.  In  Peters 's  case  it  is 
likely  the  abscess  formed  after  labor. 

T.  K.  Holmes,  of  Chatham,  was  called  in  by  Wright  and  Millen, 
of  Wheatley,  to  see  a  patient  with  the  following  history  : 

Aged  thirty,  four  months  pregnant,  chill,  fever,  pain  and  tenderness  in 
the  right  iliac  fossa.  On  twelfth  day  after  chill,  suddenly  seized  with 
severe  pain  in  the  abdomen,  followed  by  shock  and  fulness  in  the  right 
side  of  the  uterus;  in  a  few  hours  general  fulness  over  whole  abdomen. 
Diagnosis,  ruptured  tubal  pregnancy.  Operation.  Thin,  watery  pus  found 
in  the  abdominal  cavity,  appendix  sharply  bent  on  itself  and  in  an  ad- 
vanced stage  of  disease.  Appendix  removed,  abdominal  cavity  flushed, 
drainage  tube  left  in  forty-eight  hours.  Patient  recovered,  went  on  to 
full  term,  when  a  healthy  child  was  born. 

In  this  case  the  symptoms  certainly  pointed  to  ruptured  ectopic 
sac.  It  is  well,  however,  to  remember  in  such  cases  that  either  of 
the  conditions  mentioned  may  be  the  cause  of  the  symptoms  de- 
scribed.    A  mistake  in  the  other  direction  not  infrequently  occurs. 

Lusk  relates  a  case  where  several  experienced  surgeons  thought  they 
felt  a  large  and  inflamed  appendix  distinctly,  but  an  operation  showed 
that  the  lump  which  had  been  detected  was  a  tubal  ectopic  sac. 

Herbert  Bruce  reports  the  following  case:  A  patient  in  the  fourth 
month  of  pregnancy  had  acute  appendicitis  resulting  in  an  abscess.  An 
operation  was  performed.  Patient  recovered,  went  on  to  fiill  term  and 
had  a  normal  labor. 

George  Bingham  reports  the  following  case :  Acute  appendicitis  during 
fourth  month  of  pregnancy.  Operation,  No  pus.  Recovery.  Patient 
went  on  to  full  term ;  normal  labor. 

James  F.  W.  Ross  has  seen  two  patients  with  appendicitis  during 
pregnancy,  one  during  the  fourth  month  and  the  other  the  sixth.  Both 
recovered  without  operation  and  went  on  to  full  term. 

Bertram  Spencer  reported  the  following  case:  Primipara,  had  had 
three  attacks  of  appendicitis  before  pregnancy.  Had  fourth  attack  early 
in  pregnancy.  After  recovery  operation  during  fourth  month.  Appendix 
easily  removed.     Rapid  recovery.     Went  on  to  full  term;  normal  labor. 

The  following  case,  reported  by  Hirst,  shows  an  exceedingly  fortunate 
result  in  a  patient  who  might  have  been  considered  in  an  almost  hopeless 
condition  at  the  time  of  operation:  Acute  peritonitis  in  the  fifth  month 
of  pregnancy.  On  opening  abdomen  found  pools  of  pus  lying  between 
the  coils  of  intestine,  a  gangrenous  appendix,  and  two  perforations  of  the 
caput  coli.     The  pregnant  uterus  was  turned  out  of  the  abdominal  cavity, 


TUBEECULOSIS  249 

the  pus  was  carefully  sponged  out  with  gauze  pads,  the  appendix  ampu- 
tated and  the  perforations  in  the  colon  were  closed  by  a  sero-serous  stitch. 
The  uterus  was  then  returned  to  the  abdominal  cavity  and  the  wound 
closed,  with  gauze  drainage  for  eighteen  hours.  Patient  recovered  and 
went  on  to  full  term. 

TUBERCULOSIS 

The  opinions  of  authorities  as  to  tuberculosis  during  pregnancy 
are  diverse.  It  was  stated  by  one  of  America's  greatest  physicians, 
long  since  dead — George  B.  Wood — that  the  occurrence  of  preg- 
nancy undoubtedly  in  many  instances  arrests  for  a  time  the  prog- 
ress of  the  disease  and  that  lactation  appears  to  exercise  a  favor- 
able influence  over  it.  He  even  held  that  the  disease  might  be 
kept  at  bay  for  many  years  by  child-bearing  and  nursing,  so  that 
occasionally  the  predisposition  appeared  Iro  be  overcome. 

Osier  tells  us  that  pregnancy  and  parturition  hasten  the  process 
of  tuberculosis  in  almost  every  case. 

By  a  physician  who  has  perhaps  had  two  or  three  cases  under 
observation,  where  the  tuberculous  woman  rapidly  grew  worse 
during  pregnancy  and  died  before  full  term,  or  shortly  after  labor. 
Wood's  statement  may  be  received  with  surprise.  To  another 
who  has  seen  a  tuberculous  woman  improve  (apparently,  at  least) 
during  pregnancy  and  give  birth  to  a  healthy  child,  Osier's  dictum 
will  probably  not  be  acceptable. 

SYMPTOMS  OF  TUBERCULOSIS  AS  AFFECTED  BY  PREGNANCY 

Fever. — We  may  have  either  the  initial  fever,  which  generally 
occurs  with  the  tubercular  deposit,  or  we  may  have  the  fever 
of  absorption  occurring  at  a  later  stage  of  the  disease.  Either 
kind  of  fever  may  be  more  severe  than  under  ordinary  circum- 
stances, but  probably  not  as  a  rule,  excepting  in  cases  of  miliary 
tuberculosis. 

Anaemia. — Sometimes,  but  not  generally,  there  is  a  marked 
increase  of  anaemia  during  pregnancy.  We  are  more  apt,  however, 
to  have  serious  ansemia  after  labor,  especially  if  the  patient  nurses 
her  child. 

Cough. — This  is  frequently  a  very  distressing  symptom  and  is 
apt  to  become  paroxysmal  as  the  uterus  enlarges. 

Dyspnoea. — This  also  frequently  gives  rise  to  extreme  distress 
and  is  nearly  always  more  marked  toward  the  end  of  pregnancy. 


250     INTEECUEEENT    DISEASES    OF    PEEGNANCY 

Haemoptysis. — Pregnancy  does  not  appear  to  increase  the  tend- 
ency toward  haemoptysis,  excepting  in  those  cases  where  the  tuber- 
culosis becomes  seriously  aggravated  during  pregnancy. 

Abortion  and  Miscarriage. — Interruption  of  pregnancy  by  abor-' 
tion  and  miscarriage  is  not  at  all  common,  even  in  cases  where  the 
cough  is  severe  and  persistent.  I  am  unable  to  explain  why  ex- 
cessive coughing  and  vomiting  do  not  more  frequently  cause  an 
interruption  of  pregnancy. 

Effects  of  Parturition. — The  influence  of  parturition  on  a  tuber- 
culous woman  is  generally  unfavorable.  As  pointed  out  by  Rey- 
nolds-Wilson there  seems  to  be  during  pregnancy  a  certain  physi- 
ological equilibrium  as  to  the  various  functions  of  the  body  which, 
while  it  may  not  prevent  the  invasion  of  tuberculosis,  may  offer  a 
barrier  to  its  spreading.  Such  equilibrium,  however,  is  destroyed 
by  parturition.  Pain,  nervous  tension,  loss  of  blood,  and  sudden 
relaxation  following  delivery,  are  inseparable  conditions  in  labor, 
and  all  contribute  to  the  physical  exhaustion  belonging  to  the 
various  stages  of  tuberculosis.  The  effects  of  traumatism  inci- 
dent to  labor  also  seem  to  give  fresh  impetus  to  the  tuberculous 
process.  A  general  dissemination  of  tubercle,  apparently  dating 
from  delivery,  has  occasionally  been  observed. 

The  Effects  of  Lactation. — In  a  certain  proportion  of  cases  the 
disease  develops  somewhat  rapidly  during  the  puerperium.  I 
leave  out  of  consideration  now  that  rapid  general  dissemination  of 
tubercle  before  referred  to.  The  patient  generally  goes  down  still 
more  rapidly  during  lactation.  It  is  not  easy  in  all  cases  to  carry 
out  the  rule  that  a  tuberculous  woman  shall  under  no  circumstances 
nurse  her  child.  The  mother  may  have  plenty  of  milk  and  may 
never  have  passed  beyond  the  first  stage  of  phthisis.  If  it  be 
in  the  interests  of  the  child  she  may  be  very  anxious  to  nurse 
it  for  a  time  at  least.  In  this  case,  as  in  others,  we  can  not  be 
governed  entirely  by  iron  rules.  However,  we  should  always  keep 
in  view  the  fact  that  lactation  under  such  circumstances  involves 
some  danger,  and  if  not  entirely  proscribed,  should  be  curtailed  as 
much  as  possible. 

Effect  on  Child. — It  is  not  well  for  the  child  to  be  nourished  by 
the  milk  of  its  tuberculous  mother,  chiefly  because  of  the  low 
nutritive  quality  of  such  milk  generally ;  otherwise  there  is  probably 
very  little  danger  of  transmission  of  the  disease  from  mother  to 
child  through  lactation.     Tubercle  bacilli  are  very  seldom  found 


TUBERCULOSIS  251 

in  such  milk.  In  addition,  tubercular  infection  of  the  intestinal 
tract  in  the  new-born  seldom  happens. 

Liability  to  Septicaemia. — It  was  thought  at  one  time  that  a 
tuberculous  woman  was  more  apt  to  suffer  from  septicaemia  than  a 
non-tuberculous.  So  far  as  I  have  been  able  to  learn  from  clinical 
observations,  by  myself  and  others,  liability  to  septicaemia  is  not 
appreciably  increased ;  in  fact,  I  think  we  may  consider  that,  with 
ordinary  precautions  as  to  cleanliness,  etc.,  our  tuberculous  patients 
will  not  have  septicaemia. 

Effect  on  the  Foetus. — One  hardly  expects  to  find  a  healthy 
foetus  when  the  patient  has  advanced  phthisis,  but  this  is  exactly 
what  we  do  find  in  a  certain  proportion  of  cases.  One  of  the  most 
important  questions  which  can  arise  is  that  referring  to  the  possi- 
bility of  the  infection  of  the  foetus  in  utero.  Schmorl  and  Kockel 
found  tuberculous  changes  in  the  placenta  in  all  cases  of  pregnant 
women  dying  of  phthisis,  but  they  point  out  that  the  vilU  offer 
considerable  resistance  to  the  bacilli ;  even  when  the  bacilli  do  pass 
into  the  foetal  blood  they  seldom  infect  the  foetal  organs.  It 
would  seem,  from  their  observations,  that  the  foetal  tissues  do  not 
offer  a  favorable  nidus  for  tubercle. 

Apart  from  the  results  of  the  investigations  of  pathologists  in 
this  direction,  which  are  still  somewhat  nebulous,  we  know  from 
clinical  experience  that  in  many  cases  tuberculous  parents  beget 
children  without  organic  tuberculous  disease. 

It  is  supposed  by  some  that  the  foetus  may  be  infected  by  the 
father.  That  this  may  occasionally  happen  is  not  impossible,  but 
that  it  frequently  happens  is  at  least  improbable.  Direct  paternal 
infection  through  tuberculization  of  the  ovum  has  never  yet  been 
demonstrated. 

Treatment. — I  know  of  no  disease  which  requires  more  care- 
ful, intelligent,  and  patient  treatment  than  tuberculosis.  We  have 
learned  in  recent  years  that  judicious  sanatorium  treatment,  under 
constant  medical  supervision,  is  decidedly  the  most  satisfactory. 
Ordinary  treatment  at  the  home  of  the  patient  is,  under  the  best 
of  circumstances,  less  effective.  We  are  moving  in  the  right  direc- 
tion in  this  country — but  so  slowly!  The  saddest  feature,  from  an 
obstetrical  point  of  view,  is  that  no  one  in  Canada  has  made  the 
slightest  endeavor  as  yet  to  make  special  provision  for  those  suffer- 
ing from  tuberculosis  during  pregnancy.  Sanatorium  treatment  in 
our  Dominion  is  inaccessible  to  such  patients,  rich  and  poor  alike. 


252     INTEECUEEENT    DISEASES    OF    PEEGKANCY 

The  physician  should  study  both  the  disease  and  his  patient 
and  should  also  keep  in  mind  the  French  maxim:  ''The  prognosis 
of  ordinary  pulmonary  phthisis  depends  in  reality  as  much  and 
more  on  the  patient  than  on  the  disease."  One  should  look  on 
the  bright  side,  ever  remembering  that  patients  with  extensive  and 
apparently  hopeless  pulmonary  disease  frequently  recover  under 
modern  methods. 

Should  a  tuberculous  woman  be  allowed  to  marry  ?  Osier  says, 
"  No ;  especially  when  with  existing  disease  there  are  fever,  bacilli, 
etc."  He  quotes  in  connection  therewith  the  remarks  of  Dubois, 
in  which  he  thinks  there  is  much  truth.  "  If  a  woman  threatened 
with  phthisis  marries  she  may  bear  the  first  accouchement  well, 
the  second  with  difficulty,  a  third  never."  While  we  may  be  in- 
clined to  agree  with  Osier  to  a  large  extent,  and  with  Dubois  to  a 
less  extent,  still  I  think  we  should  not  formulate  cast-iron  rules. 

We  are  fond  in  these  modern  days  of  considering  tuberculosis 
a  curable  disease.  While  I  freely  admit  that  a  woman  suffering 
even  from  incipient  phthisis  would  have  a  better  chance  if  she  re- 
mained unmarried  until  her  disease  is  cured  and  has  remained  cured 
for  a  considerable  time,  I  am  not  prepared  to  say  in  her  case  that 
marriage  should  always  be  prohibited.  I  can  not  do  better  in  this 
connection  than  give  the  opinion  of  Knopf,  using  largely  his  own 
words. 

A  tuberculous  woman  should  not  marry,  but  there  are  times 
when  we  may  deviate  from  this  iron  rule.  If  we  are  in  the  pres- 
ence of  a  young,  highly  impressionable  woman,  in  the  first  stages 
of  pulmonary  tuberculosis,  who  is  engaged  to  be  married,  it  would 
be  cruel  and  unwise  to  put  a  stop  to  the  union.  The  consequent 
sorrow  brought  upon  this  young  woman  would  simply  mean  has- 
tening a  fatal  termination  of  her  disease,  while  as  a  happily  mar- 
ried woman  she  has  a  fair  chance  of  getting  well.  This  is  one  of  the 
few  instances  in  the  practise  of  medicine  where  it  becomes  the  duty 
of  the  physician  to  tell  the  husband  that  if  his  wife  becomes  preg- 
nant before  her  complete  recovery  it  means  danger  to  her  and  to 
the  child. 

Should  abortion  be  induced  on  a  tuberculous  woman,  and 
if  so,  when? 

Knopf  tells  us  never  to  bring  about  abortion,  adding  that  it 
does  not  save  the  life  of  the  tuberculous  mother.  I  think  it  would 
be  well  to  adopt  this  rule  with  slight  reservation,  having  in  mind 


TUBERCULOSIS  253 

the  possibility  of  the  occurrence  of  cases  where  the  induction  of 
abortion  may  save  the  patient's  hfe.  We  should  consider  this  ques- 
tion in  the  light  of  our  present  knowledge,  that  tuberculosis  is  a 
curable  disease  in  the  pregnant  woman  as  well  as  in  the  non-preg- 
nant person.  If,  then,  our  patient  has  tuberculosis  during  preg- 
nancy, our  duty  is  to  treat  the  tuberculosis  and  not  to  murder  the 
unborn  child. 

We  all  now  probably  agree  that  if  the  woman  is  doing  even 
fairly  well,  interruption  of  pregnancy  is  not  advisable,  but  let  us 
consider  the  patient  who  is  seriously  and  dangerously  ill.  Will  a 
violent  and  unnatural  attack  on  her  uterus  cure  her?  Will  abor- 
tion, induced  with  the  least  possible  violence,  save  her?  Knopf 
says  positively  it  will  not.  He  makes  this  statement  after  an  ex- 
tended experience  in  large  maternity  hospitals  in  the  Old  and  New 
worlds. 

I  can  conceive  that  cases  may  arise  where  physicians  might 
decide,  after  careful  consultation,  that  interference  with  pregnancy 
was  advisable  in  the  interests  of  the  mother.  I  am  not  able  now 
to  describe  definitely  the  conditions  that  should  cause  us  to  reach 
such  a  decison.  I  know  of  cases  where,  after  induced  abortion,  the 
patients  have  done  well,  but  of  these  I  know  none  where  life  could 
be  said  to  have  been  immediately  endangered  before  the  operation. 

The  induction  of  premature  labor  is  sometimes  called  for  when 
there  is  extreme  dyspnoea  and  anasarca,  or  when,  in  certain  cases 
of  miliary  tuberculosis,  the  acuteness  of  the  symptoms  not  only 
endangers  the  life  of  the  mother,  but  threatens'  the  existence  of 
the  child. 

Management  of  Labor. — The  physician  should  observe  the  fol- 
lowing rules :  Watch  the  patient  carefully ;  give  chloroform  and 
morphine  when  indicated;  complete  delivery  as  soon  as  possible, 
employing  operative  interference  when  required;  prevent  haemor- 
rhage as  far  as  possible. 

SUMMARY  OF   OPINIONS  RESPECTING  TUBERCULOSIS 

From  letters  received  from  certain  well-known  specialists  of  the 
United  States  and  Canada  I  am  able  to  extract  the  following  opin- 
ions on  certain  important  points. 

Trudeau,  of  Saranac  Lake,  considers  that  pregnancy,  labor,  and 
the  puerperal  state  generally  have  an  unfortunate  effect  on  a  tuber- 
culous mother.     He  also  thinks  that  abortion  or  premature  labor 


254     INTERCUEEENT    DISEASES    OF    PEEGNANCY 

should  be  induced  where  the  disease  is  advanced  but  not  in  the  in- 
cipient cases.  If  the  advanced  cases  are  allowed  to  go  to  term,  the 
patients  suffer  greatly  from  the  mechanical  conditions  caused  by 
the  pregnancy  and  are  apt  to  die  shortly  after,  or  even  during  labor. 
The  effects  of  modern  treatment  are  beneficial  in  the  incipient 
cases.  He  has  known  a  good  many  women  with  slight  tubercular 
lesions,  who  have  kept  out  of  doors  during  their  pregnancy  and 
gained  after  child-birth,  who  have  suffered  no  harm  from  the  preg- 
nancy, especially  when  not  allowed  to  nurse  their  children. 

With  reference  to  the  children  of  tuberculous  mothers  with 
advanced  disease  he  has  found  that  they  are  poorly  nourished  and 
generally  die  in  infancy  either  of  tuberculosis  or  some  intercur- 
rent disease.  In  incipient  cases  the  children  often  thrive  and  grow 
up  as  strong  as  other  children. 

Stubbart,  of  the  Loomis  Sanatorium,  Liberty,  tells  me  that  he 
has  not  had  much  experience  of  pregnancy  associated  with  tuber- 
culosis, but  he  thinks  that  pregnancy,  labor,  and  the  puerperal 
state  have  generally  a  serious  effect  upon  a  patient  suffering  from 
tuberculosis.  As  a  consequence  he  believes  that  abortion  or  pre- 
mature labor  should  generally  be  induced,  because  the  mother's 
life  is  of  more  value  than  that  of  the  foetus. 

Vincent  Y.  Bowditch,  of  Boston,  holds  the  opinion  that  the 
course  of  tuberculosis  is  liable  to  be  checked  in  some  cases  during 
pregnancy,  but  is  apt  to  begin  again  after  labor,  although  this  is  by 
no  means  the  universal  rule.  He  also  considers  the  induction  of 
abortion  or  premature  labor  unjustifiable  in  all  cases  except  where 
the  life  of  the  mother  is  in  jeopardy.  However  much  we  may  wish 
the  child  had  never  been  conceived,  that  is  no  ground  for  the  in- 
duction of  abortion.  As  for  the  mother,  the  presence  of  tuber- 
culosis is  not  in  itself  sufficient  ground  for  such  procedure. 

Allen  Baines  gave  me  most  of  the  facts  in  connection  with  the 
following  case :  About  thirty  years  ago  a  young  couple,  members 
of  well-known  families  in  Toronto,  were  married.  The  groom,  a 
fine  vigorous-looking  fellow,  was  supposed  to  be  healthy,  but  had 
laryngeal  phthisis.  The  bride  was  a  bright  healthy  girl.  She  con- 
tracted miliary  tuberculosis  during  pregnancy,  gave  birth  to  a 
daughter  at  full  term,  and  died  a  few  weeks  after.  The  husband, 
who  had  probably  infected  his  wife,  died  of  phthisis  in  about  four- 
teen years.  The  daughter  is  now  a  strong  healthy  girl,  aged  thirty, 
a  professional  nurse  in  Chicago. 


TUBERCULOSIS  255 

About  twelve  years  ago  I  attended  a  patient  in  labor,  for  James 
Ross,  Sr.  She  had  pulmonary  phthisis  in  the  second  stage. 
Healthy  child  born.  Dr.  Ross  and  I  thought  the  mother  was  not 
likely  to  live  many  weeks.  Mother  and  child  are  alive  now  and 
fairly  healthy. 

N.  A.  Powell  gave  me  the  following  report.  A  woman  had  ad- 
vanced phthisis  with  numerous  cavities.  Labor  early  in  the  ninth 
month.  Mother  died  a  few  weeks  after.  The  child  is  now  a 
healthy  girl,  aged  fourteen,  working  regularly  in  Eaton's  store. 

I  am  indebted  to  N.  A.  Powell  and  W.  P.  Caven  for  many  par- 
ticulars as  to  certain  patients  in  the  Sanatorium  at  Gravenhurst. 
Most  of  the  following  facts,  however,  were  communicated  to  me 
by  J.  H.  Elliott,  the  physician  in  charge.  Up  to  the  present  time 
they  have  had  altogether  in  the  Institution  five  women  suffering 
from  tuberculosis  during  pregnancy. 

Case  I.  Patient  improved  much ;  expectoration  free  from  bacilli ;  very 
slight  cough.  Left  Sanatorium.  Confined  at  her  home  three  months 
after;  labor  normal.  Shortly  after  became  engaged  in  her  usual  occupa- 
tion of  washing,  scrubbing  floors,  etc.  Disease  again  developed,  and  she 
died  eighteen  months  after  labor. 

Case  II.  Disease  fairly  advanced.  Interference  with  pregnancy 
thought  advisable.  Went  home  and  under  the  care  of  her  family  physi- 
cian. Abortion  induced  in  the  fifth  month.  Adherent  placenta;  subin- 
volution of  the  uterus.  Returned  shortly  afterward  to  the  Sanatorium. 
Health  not  improved. 

Case  III.  Pulmonary  and  laryngeal  tuberculosis.  Went  home.  Abor- 
tion induced.  Back  in  three  weeks.  Health  improving;  signs  in  the 
chest  have  disappeared. 

Case  IV.  Patient  in  advanced  stage ;  softening  and  excavation  in  one 
upper  apex  and  in  apex  of  the  lower  lobe  on  the  other  side.  Abor- 
tion induced.  (Only  operation  of  the  kind  ever  performed  at  the  Sana- 
torium.) Adherent  placenta,  free  haemorrhage;  uninterrupted  recovery. 
Disease  became  quiescent  and  remained  so.  Apparently  in  perfect 
health  now. 

Case  V.  Patient  with  pulmonary  tuberculosis,  pregnant.  Went  home. 
Latest  report  from  her,  now  near  full  term:  no  extension  of  the  disease. 

It  will  be  noticed  that  in  these  five  cases  abortion  was  induced 
on  three  patients.  In  only  one  case,  however,  did  the  physician 
of  the  Sanatorium  interfere  with  the  continuance  of  pregnancy. 
This  was  done  after  consultation  and  careful  consideration  of  three 
physicians,  all  being  agreed  as  to  the  advisability  of  the  procedure. 
18 


256     INTEECUREENT    DISEASES    OF    PEEGNAI^tcY 

As  to  the  other  two  on  whom  abortion  was  induced,  I  can  not  dis- 
cuss details,  but  in  one  I  think  the  operation  would  not  have  been 
considered  necessary  if  the  patient  could  have  been  kept  under 
careful  supervision  in  a  maternity  sanatorium.  I  sincerely  hope 
that  we  shall  soon  have  one  or  more  institutions  of  this  kind  in 
Canada.  The  patient  who  went  on  to  full  term  and  had  a  normal 
labor  died  about  eighteen  months  after,  but  it  is  quite  probable 
that,  with  ordinary  care,  good  food,  and  proper  treatment,  her  life 
could  have  been  saved. 

The  following  cases  have  been  observed  by  A.  McPhedran  and 
W.  Goldie,  as  reported  to  me  by  Goldie : 

Case  I.  Had  an  outbreak  before  marriage.  Good  health  when  mar- 
ried. Outbreak  after  marriage,  lasting  five  months.  After  this  had 
three  pregnancies  going  to  full  term.  In  good  condition  during  each 
pregnancy.  Three  children,  all  well  now.  Mother  had  an  outbreak 
after  the  last  labor,  lasting  seven  months. 

This  is  a  remarkable  history.  A  woman  with  active  tubercu- 
losis before  and  after  her  marriage  is  now  fairly  well,  with  three 
children  hving.  This  is  exactly  what  Dubois  said  could  never 
occur. 

Case  II.  Had  two  outbreaks  before  marriage.  Good  health  when 
married,  good  health  in  first  pregnancy.  Outbreak  soon  after  labor, 
lasting  six  or  seven  months.  Baby  died,  aged  four  weeks,  of  intestinal 
disturbance.  Became  pregnant  a  second  time,  five  months  after  labor, 
during  an  outbreak.  General  health  improved,  lung  symptoms  disap- 
peared, child  born  at  full  term.  Mother  remained  in  good  health  for  four 
years;  then  bacilli  found  in  sputum  during  bronchitic  attacks.  Second 
child  died,  aged  sixteen,  of  acute  pneumonic  tuberculosis.  During  sixteen 
years,  after  the  birth  of  a  second  child,  abortion  was  induced  five  times. 
Lung  symptoms  always  grew  worse  after  each  abortion. 

It  is  interesting  to  note  in  this  case  that  pregnancy  occurred 
during  an  outbreak,  that  the  lung  symptoms  soon  disappeared, 
and  the  patient  continued  well  up  to  the  time  of  labor. 

Case  III.  One  outbreak  before  marriage.  Fairly  healthy  when  mar- 
ried. During  first  pregnancy  had  better  health  than  before  marriage,  but 
during  lactation  had  an  outbreak  which  lasted  for  a  few  months.  Child 
is  very  neurotic  and  has  tuberculous  cervical  adenitis. 

Case  IV.  Condition  before  marriage  unknown.  Had  tuberculosis,  at 
least,  for  many  years  of  married  life.     Had   six   children.     One   child 


CARDIAC    DISEASES  257 

died  in  infancy,  mother  "coughing"  at  the  time.  Another  died  aged 
eighteen,  of  acute  pneumonic  tuberculosis.  Some  improvement  in  health 
during  last  pregnancy,  but  she  died  two  weeks  after  labor.  Child  now 
aged  twenty  and  in  good  health. 

Case  V.  Condition  before  marriage  unknown.  Has  had  chronic  fibroid 
phthisis  probably  during  the  whole  of  her  married  life.  Is  fairly  healthy. 
Only  one  serious  outbreak  after  second  labor.  Had  four  children.  Three 
died  of  pneumonic  tuberculosis,  all  aged  over  sixteen.  The  oldest  son  has 
now  pulmonary  tuberculosis. 

In  some  cases,  especially  of  laryngeal  phthisis,  the  dyspnoea 
may  be  so  serious  as  to  endanger  life  or  even  cause  death.  This 
is  well  illustrated  by  a  case  reported  to  me  by  George  McDonagh. 

About  twelve  years  ago  he  saw  a  patient  with  Frederick  Win- 
nett,  early  in  the  first  stage  of  labor.  The  dyspnoea  was  so  pro- 
nounced that  they  feared  every  minute  that  the  woman  would 
become  asphyxiated.  Intubation  was  at  once  performed.  In- 
stantaneous relief  was  afforded  and  labor  progressed  favorably. 
Healthy  child  was  born,  but  the  mother  died  two  days  after  the 
intubation. 

CARDIAC  DISEASES 

The  subject  of  cardiac  disease  is  very  interesting  to  the  obstet- 
rician from  many  points  of  view,  particularly  in  connection  with 
marriage,  pregnancy,  and  labor.  Certain  questions  arise  in  the 
consideration  of  these  various  points,  especially  in  their  practical 
or  clinical  aspects. 

Marriage  Not  Prohibited. — Should  a  woman  with  valvular  car- 
diac disease  be  allowed  to  marry?  I  think  the  answer  to  this 
question  should  be:  "Yes,  with  certain  exceptions."  Matrimony 
should  not  be  forbidden  when  a  lesion  in  the  heart  is  compen- 
sated and  no  complication  has  arisen;  but  it  should  be  forbidden 
when  there  are  any  serious  symptoms  of  cardiac  disturbance  pres- 
ent, attacks  of  dyspnoea,  breathlessness,  palpitation  on  exertion,  or 
haemoptysis. 

In  a  large  proportion  of  cases,  probably  the  majority,  the  physi- 
cian is  not  consulted  in  the  matter.  Frequently  the  refusal  to 
sanction  a  marriage  makes  no  difference  in  the  course  of  events. 
I  have  for  years  entertained  the  opinion  that  a  young  woman  hav- 
ing valvular  lesions  of  the  heart,  who  can  carry  out  her  social  and 
domestic  duties  without  any  serious  symptoms  of  ill  health,  should 


258     INTERCUERENT    DISEASES    OF    PREGNANCY 

not  be  prevented  from  marrying,  although  I  freely  admit  that 
child-bearing  is  likely  to  aggravate  the  dangers  connected  with 
heart  disease.  I  may  say  at  the  same  time  that  I  fear  the  dan- 
gers of  pregnancy  and  labor  in  such  patients  less  than  I  did  some 
time  ago. 

In  one  case  a  young  woman  was  married  contrary  to  the 
advice  of  her  physician,  and  when  pregnancy  promptly  followed, 
the  young  bride  and  her  mother  fully  realized  the  serious  aspects 
of  her  condition  and  asked  their  physician  to  induce  an  abor- 
tion. When  called  in  consultation  I  refused  to  consent  to  such 
procedure  on  account  of  the  absence  of  any  serious  symptoms. 
This  young  woman  is  now  the  mother  of  two  healthy  children 
aged  four  and  two  respectively,  and  is  herself  enjoying  fairly  good 
health. 

Serious  Heart  Lesions, — Which  of  the  heart  lesions  is  the  most 
serious?  It  is  generally  acknowledged  that  mitral  stenosis  is  the 
most  dangerous  condition.  This  was  pointed  out  very  clearly 
many  years  ago  by  Angus  Macdonald,  and  writers,  since  the  pub- 
lication of  his  work,  such  as  Galabin,  Berry  Hart,  and  others,  agree 
with  him.  The  rarer  conditions  of  aortic  stenosis  and  aortic 
regurgitation  are  dangerous,  but  not  so  much  so  as  the  mitral  sten- 
osis. Mitral  regurgitation  alone  is  not  as  a  rule  a  matter  of  serious 
import. 

Effect  of  Pregnancy. — How  does  pregnancy  affect  the  system 
in  cases  of  heart  disease?  It  is  apt  to  disturb  compensation  and 
the  backward  pressure  may  primarily  overload  the  pulmonary  cir- 
culation, causing  serious  thoracic  complications  and  interference 
with  the  functional  activity  of  other  organs,  especially  the  kidneys 
and  liver.  Sometimes  the  general  disturbance  induced  causes 
abortion,  although  I  think  not  so  often  as  has  generally  been  sup- 
posed. 

I  formerly  thought  that  the  loss  of  balance  throughout  the 
system  was  apt  to  cause  eclampsic  toxaemia;  but,  although  albu- 
minuria and  dropsy  are  common  complications,  I  am  now  doubtful 
about  the  frequency  of  convulsions  in  such  cases.  In  many  of  the 
cases  pregnancy  appears  to  produce  no  ill  effects  whatever.  Dakin 
says  that  sometimes  the  patients  appear  to  improve  during  preg- 
nancy, owing  to  the  hypertrophy  of  the  heart  natural  to  this 
period.  Some  of  my  patients,  especially  those  having  mitral 
insufficiency,  have  seemed  better  during  pregnancy  than  they  were 


CARDEAC    DISEASES  259 

before,  but  sometimes  they  have  lost  ground  after  labor,  especially 
during  lactation. 

Treatment  During  Pregnancy. — Notwithstanding  the  favorable 
issue  in  a  large  proportion  of  cases,  every  patient  should  be  care- 
fully watched  during  pregnancy  and  should  be  carefully  treated 
when  serious  symptoriis  appear.  The  following  rules  should  be 
observed  in  such  cases : 

1.  Keep  the  'patient  at  rest  without  going  to  extremes.  A  certain 
amount  of  exercise  and  recreation  is  frequently,  if  not  generally, 
beneficial.  Enjoin  absolute  rest,  however,  if  serious  symptoms 
appear. 

2.  //  the  equilibrium  of  the  circulation  is  disturbed,  as  shown 
by  the  ordinary  pulmonary  symptoms  of  dyspnoea,  etc.,  administer 
cathartics,  especially  calomel  followed  by  Epsom  salts. 

I  believe  that  in  cardiac  disease  of  pregnancy  with  serious  symp- 
toms, especially  if  there  is  systemic  toxaemia,  the  proper  admin- 
istration of  Epsom  salts  will  accomplish  more  good  than  all  other 
remedies  (including  rigid  dieting)  put  together.  Next  to  saline 
cathartics  I  would  place  strychnine  and  digitalis  (or  strophanthus). 
For  marked  dyspnoea  one  may  use  nitrite  of  amyl,  which  affords 
more  prompt  relief  for  this  distressing  symptom  than  any  other 
medicine,  so  far  as  my  experience  goes.  Frequent  dry  cupping  of 
the  thorax  in  the  region  of  the  heart  is  at  times  beneficial  and  is 
always  safe. 

3.  Regulate  the  diet.  A  great  many  still  believe  with  Char- 
pentier,  Vinay,  and  others,  that  a  milk  diet  in  these  cases  is  the 
best.  I  allow  and  generally  encourage  my  patients  to  drink  as 
much  milk  as  they  like,  but  no  more. 

The  patient  may  select  from  the  following:  milk,  buttermilk, 
kumiss,  tea,  water,  lemonade,  table  mineral  waters,  fish,  oysters, 
most  acid  fruits  (strawberries  doubtful,  frequently  injurious),  green 
vegetables,  including  spinach,  lettuce,  cabbage,  cauliflowers,  celery, 
radishes,  rhubarb,  green  peas,  and  beans,  green  corn  on  the  cob, 
carrots,  onions,  pickles,  table  bread,  breakfast  rolls,  toast,  pota- 
toes, a  limited  amount  of  pepper,  salt,  and  vinegar  for  flavoring, 
oatmeal,  corn-meal,  rice,  tapioca,  and  the  like.  Chicken  every 
other  day.     Any  kind  of  meat  once  a  week. 

She  should  avoid  meats  excepting  as  recommended,  meat 
broths,  eggs,  cheese,  asparagus,  sweet  potatoes,  turnips,  beets, 
sirups,   candies,  sweet    fruits,  such  as  grapes,  bananas,  raisins, 


260     INTEECURKENT    DISEASES    OF    PEEGNANCY 

pears  and  preserved  fruits.     If  there  is  no  albuminuria  meat  and 
eggs  may  be  added  to  the  prescribed  list. 

4.  Give  no  diuretic  remedies  excepting  water. 

5.  Recommend  the  ordinary  daily  warm  bath  to  keep  the  skin 
acting  properly  and  nothing  else.  The  wet  pack,  so  dear  to  some 
physicians,  is,  I  think,  useless  and  frequently  objectionable. 

6.  It  is  sometimes  advisable  to  induce  abortion.  This  radical 
method  of  treatment  is  seldom  required.  If  marked  failure  of 
compensation  occurs  early  in  pregnancy,  as  shown  by  serious  pul- 
monary congestion,  urgent  dyspnoea,  and  the  like,  the  patient 
should  in  the  first  place  receive  appropriate  treatment.  If  the 
symptoms  become  worse  instead  of  better,  operative  interference 
may  be  deemed  advisable.  Many  women,  especially  Roman  Cath- 
olics, will  not  consent  to  any  such  procedure.  Of  course,  in  such 
instances  the  patient's  decision  should  be  final.  It  is  extremely 
difficult  to  lay  down  definite  rules.  I  am  less  inchned  to  interfere 
in  such  cases  than  I  was  years  ago. 

The  following  case,  hereafter  described  as  Case  II,  caused  me 
much  perplexity  but  was  very  instructive : 

Patient,  three  months  advanced  in  pregnancy,  had  mitral  stenosis. 
Had  severe  dyspnoea  on  exertion,  palpitation,  rapid  pulse.  Similar  symp- 
toms had  appeared  before  pregnancy  on  various  occasions.  At  one  time 
the  pulmonary  congestion  was  marked  and  caused  haemoptysis.  After 
careful  deliberation,  and  with  considerable  hesitation,  we  decided  to  wait 
for  one  month,  and  watch  the  effect  of  treatment.  The  patient  went  on 
to  full  term. 

It  has  been  pointed  out  by  Hanfield-Jones  and  others  that  many 
women  go  through  early  pregnancies  with  comparatively  little 
danger,  but  each  pregnancy  causes  a  certain  deterioration  of  the 
heart  muscle  which  is  more  or  less  permanent ;  therefore,  the  dan- 
ger of  cardiac  insufficiency  becomes  greater  with  each  successive 
pregnancy.  This  does  not  apply  to  all  cases;  I  have  seen  more 
than  one  patient  in  whom  pregnancy  did  not  cause  any  apparent 
deterioration  of  the  heart  muscle. 

7.  We  have  sometimes  to  consider  the  advisability  of  inducing 
premature  labor.  Angus  Macdonald  was  decidedly  opposed  to  this 
procedure,  because  it  was  "likely  to  do  greater  harm  than  good 
by  disturbing  the  action  of  the  heart  and  the  condition  of  the  lungs." 
I  think  there  is  a  pretty  general  consensus  of  opinion  among 


CAKDIAC    DISEASES  261 

obstetricians  who  have  devoted  much  attention  to  this  subject  that 
these  views  are  correct.  My  own  experience  leads  me  to  beHeve 
that  the  patient  has  the  best  chance  when  this  operation,  which  is 
always  more  or  less  an  act  of  violence,  is  not  performed.  The  rule 
is  not  to  induce  premature  labor  in  such  cases ;  but  it  is  not  abso- 
lute. It  might  happen  that  some  symptoms  would  arise  so  urgent 
in  nature  that  interference  should  be  considered  necessary. 

Effect  on  Labor. — How  does  valvular  disease  of  the  heart  affect 
labor?  I  am  not  sure  that  it  produces  any  visible  effect  in  the 
majority  of  cases.  I  have  sometimes  looked  forward  to  certain 
labors  with  fear  and  trembling;  and,  much  to  my  surprise,  have 
frequently  found  them  apparently  normal  in  all  respects. 

Symptoms. — The  symptoms  during  labor  are  not  generally  dif- 
ferent from  those  which  are  found  during  the  last  few  days,  or 
even  weeks,  of  pregnancy.  The  most  serious  are  dyspnoea,  haemo- 
ptysis, prsecordial  distress  and  palpitation.  Respiration  and  pulse 
are  generally  much  quickened.  The  dyspnoea  and  other  symptoms 
are  aggravated  when  the  patient  is  in  the  recumbent  posture.  On 
this  account  the  patient  is  in  many  cases  compelled  to  sit  up  wholly 
or  partially  even  while  sleeping. 

Prognosis. — Careful  observers  give  mortality  rates  ranging  from 
10  to  60  per  cent.  Many  writers  who  treat  the  subject  carefully 
in  other  respects  fail  to  give  statistics,  I  think  it  unfortunate  that 
such  is  the  case,  because  I  believe  more  complete  details  as  to 
results  would  show  mortality  rates  much  less  alarming  than  those 
which  I  have  quoted.  I  believe  that  the  publication  of  such  reports 
has  caused  many  practitioners  to  induce  abortion  when  there  is  no 
necessity  for  such  procedure. 

No  statement  has  surprised  me  more  than  that  made  in  three 
modern  American  text-books  on  midwifery,  viz.,  Jewett's  Practise 
of  Obstetrics  by  American  Authors ;  the  American  Text-book  of 
Obstetrics,  and  Davis's  Treatise  on  Obstetrics — that  in  cases  of 
mitral  insufficiency  the  proportion  of  deaths  is  13  per  cent.  In 
the  three  books  there  is  little  or  no  evidence  as  to  the  origin  of  the 
unlucky  thirteen.  In  connection  with  the  statistics  referred  to  I 
can  not  help  thinking  that  various  authors  have  been  misunder- 
stood, because  they  have  referred  to  those  cases  only  where  com- 
pensation has  been  seriously  interfered  with.  In  addition,  it  is  well 
to  remember  that  some  of  these  statistics  are  founded  on  results 
obtained  during  the  pre-Listerian  era.     Judging  from  what  I  have 


262      INTEECUEEENT    DISEASES    OP    PEEGNANCY 

observed  I  am  fully  convinced  that  the  mortality  rates  which  I 
have  quoted,  i.  e.,  10  to  60  per  cent.,  are  altogether  wrong,  or  at 
least  misleading.  Some  of  our  physicians  appear  to  take  a  less 
gloomy  view  than  the  obstetricians.  Osier,  in  speaking  of  valvular 
lesions  of  the  heart,  says :  ' '  Pregnancy  and  parturition  are  dis- 
turbing factors,  but  are,  I  think,  less  serious  than  some  writers 
would  have  us  believe." 

Treatment  During  Labor. — I  have  already  indicated  the  medi- 
cines which  are  generally  recognized  as  most  suitable  during  preg- 
nancy. The  same  line  of  treatment  should  be  carried  out  during 
labor.  Strychnine  and  digitalis  (or  strophanthus)  are  given  to  help 
the  heart's  action;  nitrite  of  amyl  or  nitroglycerin  (glonoin)  for 
dyspnoea  and  prsecordial  distress.  The  amyl  acts  more  promptly, 
while  the  glonoin  acts  well  when  given  in  small  doses  for  days  at 
'  a  time  during  the  latter  part  of  pregnancy.  The  application  of  a 
cupping-glass  over  the  heart  helps  both  dyspnoea  and  irregularity 
of  pulse.  Chloroform  should  be  administered  during  the  latter 
part  of  the  first  and  the  whole  of  the  second  stage  of  labor. 

Many  obstetricians  in  Canada  and  elsewhere  think  that  chloro- 
form is  dangerous  in  labor  if  the  patient  has  heart  disease.  At  one 
time  I  held  a  similar  opinion,  but  increased  experience  leads  me  to 
believe  that  chloroform  is  not  dangerous;  on  the  other  hand,  I 
think  it  materially  aids  in  mitigating  some  of  the  serious  symp- 
toms. Fothergill  says  that  heart  disease  in  labor  is  no  contra- 
indication for  chloroform.  Ether,  as  a  rule,  is  contraindicated, 
particularly  on  account  of  the  pulmonary  complications. 

The  patient  should  be  prevented  from  straining  or  ''bearing 
down."  At  the  completion  of  the  first  stage  it  is  better,  as  a  rule, 
to  deliver  with  the  forceps.  Sometimes  the  patient  should  be 
allowed  to  sit  with  her  head  and  shoulders  held  up  or  propped  up 
with  pillows.  It  is  sometimes  advisable  to  have  the  patient  in 
such  a  position  that  her  buttocks  are  projecting  over  the  edge  of 
the  bed,  while  an  assistant  stands  on  either  side  grasping  a  leg  or  a 
thigh  and  foot  so  as  to  prevent  her  from  slipping  on  to  the  floor. 
It  is  well  to  apply  an  abdominal  binder  before  delivery,  which 
should  be  tightened  during  the  passage  of  the  child.  At  the  same 
time  a  free  hsemorrhage  is  beneficial  and  should  be  encouraged. 
The  object  of  the  binder  is  to  compensate  for  the  sudden  diminu- 
tion of  the  intra-abdominal  pressure.  It  should,  therefore,  be 
applied  above  the  level  of  the  uterus  in  such  a  way  that  it  will  not 


CARDIAC    DISEASES  263 

prevent  slight  uterine  relaxation,  or,  in  other  words,  in  such  a  way 
as  not  to  prevent  free  hiemorrhage.  With  the  same  object  in  view 
the  use  of  ergot  should  be  avoided.  Fothergill  and  others  advise 
free  venesection  from  the  arm  if  symptoms  of  embarrassed  circu- 
lation persist. 

Hart  says  that  the  most  dangerous  time  for  the  patient  in  such 
cases  is  the  third  stage.  This  is  probably  correct,  but  it  is  well  to 
remember  that  grave  danger  exists  for  several  days  after  delivery, 
and,  in  fact,  very  watchful  care  is  required  for  weeks. 

I  shall  not  now  make  any  further  reference  to  mitral  insuffi- 
ciency. Not  long  since  I  presented  to  one  of  our  medical  societies 
a  report  of  eight  cases  of  mitral  stenosis,  sometimes  accompanied 
by  aortic  stenosis.  From  these  I  shall  select  four,  which  furnish 
various  points  of  interest.  One  of  the  cases  I  shall  give  in  detail 
because  it  was  in  several  respects  the  most  serious  and  the  most  in- 
teresting I  have  ever  seen,  and  also  because  it  shows  the  general 
line  of  treatment.  Among  the  eight  cases  one  patient  died,  while 
seven  made  good  recoveries.  The  patient  who  died  got  through 
her  labor  fairly  well  and  progressed  favorably  for  several  days 
afterward  until  the  sixth  day,  when  death  occurred  suddenly.  I 
think  it  quite  possible  that  this  patient  might  have  been  saved  if 
she  had  been  properly  nursed  in  a  comfortable  home  or  hospital. 

Case  I.  Mrs.  K.,  aged  thirty-two.  I  para.  Dr.  Caven's  patient.  Saw 
her  in  consultation  when  three  months  advanced  in  pregnancy.  For  two 
or  three  years  previously  she  suffered  more  or  less  from  symptoms  due 
to  heart  disease.  Dyspnoea  on  exertion  very  serious  at  times;  a  few  at- 
tacks of  hsemoptysis;  mitral  stenosis;  loud  presystolic  murmur.  Dr. 
Caven  feared  results  if  pregnancy  were  allowed  to  continue.  I  advised 
waiting  at  least  a  month.  We  decided  on  so  doing  with  the  understand- 
ing that  I  was  to  take  charge  of  the  patient.  No  serious  symptoms  after- 
ward. In  fact,  she  seemed  better  during  the  latter  half  of  pregnancy 
than  during  the  first  half.  Labor — at  full  term — uneventful  up  to  the 
end  of  the  first  stage;  no  chloroform  administered;  delivered  with  forceps; 
healthy  child ;  good  recovery. 

Case  II.  Mrs.  S.,  aged  thirty-two.  II  para.  Dr.  Graef's  patient.  Saw 
her  in  consultation  early  in  labor.  She  had  suffered  much  during  preg- 
nancy from  dyspnoea  and  marked  praecordial  distress.  When  I  arrived 
labor  was  slightly  advanced;  os  partially  dilated.  She  was  suffering 
much  from  dyspnoea  and  distress  in  the  region  of  the  heart;  she  was 
unable  to  lie  down;  had  a  well-marked  presystolic  murmur;  also  aortic 
murmur.     Inhalation  of  nitrite  of  amyl  afforded  marked  relief.     We  also 


264     INTEECUREENT    DISEASES    OF    PEEGNANCY 

administered  strychnine  and  digitalis  and  a  little  chloroform.  I  was 
unable  to  remain  long;  Dr.  Graef  delivered  her  with  forceps  about  four 
hours  after  I  left;  child  dead;  patient  appeared  to  be  doing  fairly  well 
for  some  days,  died  somewhat  suddenly  the  sixth  day  after  delivery. 
Patient  was  a  poor  woman,  living  in  a  small  house  without  any  conven- 
iences ;  no  proper  nursing.     She  refused  to  go  to  a  hospital. 

Case  III.  Mrs.  X.,  aged  thiry-five.  Primipara.  Had  suffered  for  years 
from  mitral  stenosis  and  had  been  under  the  care  of  Dr.  Caven,  who  con- 
sulted me  about  the  case  and  requested  me  to  help  him  in  her  confine- 
ment. When  labor  commenced  Dr.  Caven  was  out  of  town  and  I  took 
charge.  Labor  fairly  easy  for  an  old  primipara;  no  serious  symptoms, 
but  patient  had  two  large  pillows  under  head  and  shoulders ;  waited  about 
half  an  hour  after  full  dilatation,  because  symptoms  were  not  urgent,  and 
I  was  afraid  of  the  perinseum;  administered  a  little  chloroform;  finally 
deUvered  easily  with  forceps.  I  had  a  competent  and  experienced  nurse 
to  assist  me,  and  did  not  call  any  one  in  to  administer  the  anaesthetic.  I 
would  not,  however,  advise  others  to  follow  my  example  in  this  respect. 
Healthy  child.     Good  recovery. 

Case  IV.  Mrs.  C,  aged  thirty.  Ill  para.  She  had  been  under  the 
care  of  Dr.  J.  F.  W.  Ross,  in  the  PaviHon  of  the  Toronto  General  Hospital. 
He  sent  her  to  the  Burnside  Lying-in  Hospital  to  be  placed  under  my 
care  during  her  confinement.  She  had  been  suffering  for  some  years 
from  mitral  stenosis.  I  first  saw  her  in  the  Burnside  three  days  before 
the  onset  of  labor.  She  had  severe  bronchial  catarrh  with  slight  haemop- 
tysis at  times,  urgent  dyspnoea,  and  marked  praecordial  distress.  Was 
unable  to  lie  down  even  for  a  few  minutes,  but  lay  propped  up  in  bed 
almost  in  a  sitting  posture.  Her  sufferings  were  great  and  her  general 
condition  alarming.  After  a  consultation  with  Dr.  Ross,  we  decided  not 
to  interfere,  but  to  watch  and  treat  symptoms.  Dr.  Ross  had  prescribed 
strychnine,  digitalis,  and  stimulants.  I  continued  on  the  same  line,  also 
prescribed  amyl  nitrite,  to  be  administered  occasionally.  Her  respira- 
tions were  rapid,  between  40  to  50  at  times.  Pulse  from  120  to  170, 
sometimes  could  not  be  counted.  Patient  was  very  carefully  watched  by 
the  resident  assistants,  and  the  head  nurse.  Miss  McKellar.  I  feared  she 
would  not  live  until  labor  commenced,  but  did  not  feel  that  I  dared  inter- 
fere. Labor  commenced  on  the  morning  of  January  27th,  and  continued 
during  the  day.  The  os  was  fully  dilated  at  5  p.  m.  Dr.  McEachren 
administered  chloroform,  the  patient  being  held  in  the  sitting  posture 
on  the  edge  of  the  bed  by  two  members  of  the  resident  staff,  while  I  de- 
livered with  forceps.  A  binder  was  put  around  the  abdomen,  and  tight- 
ened during  and  after  delivery.  Fairly  free  haemorrhage  followed  and 
was  encouraged.  The  dyspnoea  and  distress  continued  for  hours.  At 
times  we  thought  she  was  dying.  We  gave  strychnine  and  digitalis  and 
small  doses  of  whisky,  but  she  was  still  unable  to  lie  down  for  some  days 
after  delivery.     About  the  fourth  day  the  symptoms  became  less  severe. 


SYPHILIS  265 

After  that,  recovery  was  somewhat  rapid,  and  in  one  month  she  went  out 
of  the  Burnside  fairly  well.  The  baby  was  healthy,  though  not  large, 
and  became  a  great  pet  among  the  nurses.  He  left  the  hospital  with  his 
mother,  under  the  properly  legalized  name  of  Adam  Ross  Cooper.  The 
onlookers,  and  others  who  heard  of  the  case,  were  surprised  at  the  admin- 
istration of  chloroform  under  such  circumstances,  but,  as  I  have  already 
discussed  this  procedure,  I  shall  only  add  that  I  beheve  the  chloroform 
was  a  decided  benefit  to  the  patient. 

SYPHILIS 

The  local  primary  manifestations  of  this  disease  are  very  serious 
on  account  of  the  hyperaemia  of  the  pelvic  organs  during  pregnancy. 
The  period  of  incubation  is  generally  two  weeks,  although  it  may 
occasionally  be  longer — up  to  six  weeks.  The  initial  lesion  de- 
velops rapidly  and  extends  over  a  large  area,  affecting  sometimes 
the  vagina,  the  vulva,  nates,  and  the  inner  sides  of  the  thighs. 
There  are  also  reddening  and  excoriation  of  the  skin  and  mucous 
membrane,  oedema,  eczema,  and  occasionally  abscesses  and  ex- 
tensive sloughing. 

We  have  the  three  stages  under  ordinary  circumstances,  but 
when  the  disease  is  contracted  during  pregnancy  the  primary 
symptoms  are  those  which  are  most  marked.  The  second  stage 
is  comparatively  mild  and  unaccompanied  by  the  ordinary  syphi- 
litic fever.  There  is,  however,  a  certain  proportion  of  cases  accom- 
panied by  fever,  but  this  fever  is,  I  think,  more  apt  to  occur  in  the 
primary  stage.  We  have  to  consider  the  disease  in  three  aspects  : 
1,  As  to  the  effect  on  the  mother;  2,  as  to  the  effect  on  the  foetus  ; 
3,  as  to  the  tendency  to  cause  abortion. 

Mother. — Although  the  symptoms,  apart  from  those  associated 
with  the  primary  manifestations,  are  generally  mild,  it  happens 
that  in  a  certain  proportion  of  cases  the  disease  is  accompanied  by 
serious  symptoms,  especially  when  septic  bacteria  are  added  to 
the  germs  of  syphilis.  In  the  majority  of  instances  the  disease, 
as  far  as  the  mother  is  concerned,  may  be,  to  a  large  extent  at  least, 
controlled  by  careful  and  judicious  treatment. 

Foetus. — As  far  as  the  foetus  or  child  is  concerned  the  prog- 
nosis is  more  favorable  in  syphilis  acquired  during  pregnancy  than 
when  it  has  existed  before  impregnation.  When  it  is  acquired 
during  fruitful  coitus,  or  very  early  in  pregnancy,  the  foetus  will 
probably  die;  when  acquired  late  in  pregnancy  the  foetus  will 


266     INTEKCUEEEj^'T    DISEASES    OF    PEEGNANCY 

probably  live.  The  child  may  occasionally  be  infected  during 
labor. 

Tendency  to  Cause  Abortion. — Practically  death  of  the  embryo 
or  foetus  means  abortion.  When  a  syphilitic  woman  becomes 
pregnant  early  abortion  usually  occurs,  and  in  succeeding  preg- 
nancies abortion  generally  recurs,  but  it  often  happens  that  each 
abortion  occurs  a  little  later  than  that  which  immediately  pre- 
ceded it. 

When  the  father  has  syphilis  a  number  of  years  before  marriage 
and  the  mother  is  free  from  the  disease,  the  father,  if  he  has  tertiary 
syphilis,  may  infect  the  child.  In  consequence,  the  child  may  die 
or  may  be  born  with  syphilis  or  may  develop  it  within  a  few  weeks. 
The  mother  at  the  same  time  may  show  none  of  the  ordinary  symp- 
toms of  syphilis,  and  yet  we  know  that  every  woman  under  these 
circumstances  is  to  some  extent  affected. 

Hereditary  Transmission. — According  to  Osier  this  is  most  com- 
mon from:  (a)  The  father,  the  mother  being  healthy  (sperm  in- 
heritance) .  Congenital  syphilis  from  paternal  infection  is  only  too 
common.  A  syphilitic  father  may,  however,  beget  a  healthy  child. 
On  the  other  hand,  in  very  rare  instances,  a  man  may  have  had 
syphilis  when  young,  undergone  treatment,  and  for  years  presented 
no  signs  of  disease,  and  yet  his  first-born  may  show  very  char- 
acteristic lesions.  Generally,  however,  if  the  treatment  has  been 
thorough,  the  offspring  escapes.  The  closer  the  begetting  to  the 
primary  sore  the  greater  the  chance  of  infection,  A  man  with 
tertiary  lesions  may  beget  healthy  children.  As  a  general  rule  it 
may  be  said  that  with  judicious  treatment  the  transmissive  power 
rarely  exceeds  three  or  four  years. 

(6)  Maternal  transmission  (germ  inheritance).  It  is  a  remark- 
able and  interesting  fact  that  a  woman  who  has  borne  a  syphilitic 
child  is  herself  immune  and  can  not  be  infected,  though  she  may 
present  no  signs  of  the  disease  (CoUes's  law).  In  the  majority  of 
such  cases  the  mother  has  received  a  sort  of  protective  inoculation 
without  having  had  actual  manifestations  of  the  disease.  A  woman 
with  acquired  syphilis  is  liable  to  bear  infected  children.  The 
father  may  not  be  affected.  In  a  large  number  of  instances  both 
parents  are  diseased,  the  one  having  infected  the  other,  in  which 
case  the  chances  of  foetal  infection  are  greatly  increased. 

The  following  important  practical  question  arises.  Should  an 
apparently  healthy  woman,  who  has  given  birth  to  a  syphilitic 


SYPHILIS  267 

child,  be  permitted  to  suckle  it?  "Yes.  She  may  suckle  her  child 
in  safety  without  contracting  syphilis  from  it."  In  the  same  con- 
nection another  interesting  question  arises.  Should  a  healthy  wet- 
nurse  be  allowed  to  suckle  the  child?  "Decidedly  no,  because 
if  she  does  she  will  likely  get  the  disease  from  the  child."  I  think 
it  is  Fournier  who  makes  the  statement  that  laws  should  be 
enacted,  positively  forbidding  healthy  women  from  nursing  syph- 
ilitic children. 

(c)  Placental  transmission.  The  mother  may  be  infected  after 
conception,  in  which  case  the  child  may  be,  but  is  not  necessarily, 
born  syphilitic. 

Syphilitic  Fever. — As  before  intimated,  we  do  not  frequently 
find  syphilitic  fever  during  the  secondary  stage  either  in  the  preg- 
nant or  puerperal  state,  although  we  have  every  reason  to  believe 
that  it  does  occur  in  a  small  proportion  of  cases.  I  think,  as  be- 
fore stated,  that  syphilitic  fever,  in  connection  with  pregnancy  or 
the  puerperium,  is  more  apt  to  occur  during  the  primary  stage 
while  the  initial  lesion  is  so  well  marked.  As  an  instance  of  this 
the  following  case  is  related,  as  reported  for  me  by  Dr.  Helen 
MacMurchy: 

A.  K.,  aged  seventeen.  Under  care  of  Dr.  A.  H.  Wright  at  Burnside. 
At  the  onset  of  labor,  July  17th,  1901,  the  head  nurse  reported  a  sore  (of 
which  the  patient  had  never  before  complained)  upon  the  inner  aspect  of 
the  right  labium  minus.  On  examination  this  sore  was  found  to  be  much 
inflamed  and  indurated,  about  2  inches  in  length  and  1  inch  broad,  with 
a  central  ulcer  of  characteristic  appearance.  Child  delivered  by  axis 
traction  forceps,  no  laceration.  The  accompanying  copy  of  the  Burn- 
side  chart  shows  the  temperature  and  indicates  the  involution  of  the 
uterus.  Thus  the  position  of  the  umbilicus  O  is  5^  inches  (13  cm.)  above 
the  symphysis  pubis,  and  the  fundus  uteri,  on  the  fourth  day,  was  4 
inches  (10  cm.)  above  the  symphysis.  No  explanation  of  the  high  tem- 
perature suggested  itself,  except  that  it  was  due  to  syphilitic  infection, 
and  the  patient  gave  a  history  which  supported  this  view.  Iodoform 
and  calomel  were  dusted  freely  over  the  sore  but  caused  so  much  irrita- 
tion that  a  solution  of  lysol,  1  dram  to  the  pint,  was  used  instead.  Inter- 
nally, 20  minims  of  hydrarg.  bichlor.  1  in  1000  was  given  four  times 
a  day,  well  diluted,  but  this  treatment  had  to  be  discontinued  at  the  end 
of  a  week  on  account  of  nausea.  An  inunction  of  ung.  hydrarg.  was  then 
ordered.  August  13th  patient  discharged,  sore  almost  entirely  healed,  no 
other  symptoms  developed.  September  4th  reported  herself  quite  well 
and  strong,  but  there  was  an  eruption  on  the  child  which  was  thought 
to  be  specific. 


268     IXTEECUREENT    DISEASES    OF    PREGKANCY 

Marriage. — Fothergill  gives  the  following  rules  as  to  marriage. 
A  man  who  has  syphilis  must  not  marry:  1,  Until  he  has  under- 
gone a  course  of  mercurial  treatment.  2,  Until  three  or  four  years 
have  elapsed  from  the  time  of  infection.  3,  Until  he  has  remained 
free  from  symptoms  for  one  and  a  half  or  two  years.  Cerebral 
symptoms  should  always  prevent  marriage. 

Treatment. — Every  pregnant  woman  who  has  syphilis  before 
pregnancy,  or  contracts  it  during  pregnancy,  or  has  been  impreg- 


106° 
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Fig.  117. 


nated  by  a  syphilitic  man,  should  undergo  a  course  of  systematic 
treatment  and  should  receive  mercury  and  iodide  of  potassium. 
As  to  mercury,  the  preparations  most  commonly  used  are  the  bi- 
chloride and  protiodide.  The  bichloride  and  iodide  of  potash  may 
be  given  together  as  in  the  following  formula : 

IJ  Potassi  iodidi 3  ij  vel.    3  iv  ; 

Hydrarg.  chlor.  corros gr.  ss 

Sirup  aurant.  cort f  1  -j ; 

Aquae q.s.  ad.  f.  1  ij. 

M.  Sig.  One  teaspoonful  in  milk  three  times  a  day. 

The  protiodide  of  mercury  may  be  administered :  J-|-  grain  in 
pill  form  three  times  a  day,  and  every  second  day  add  one  pill, 
carefully  watching  the  effect  on  the  patient  at  the  same  time. 
When  the  drug  shows  its  physiological  effects  by  griping  pains  in 


GONOERHCEA  269 

the  bowels,  or  diarrhoea,  or  fetid  breath  with  tenderness  of  the 
gums,  the  dosage  shoidd  be  cut  down  by  one-half.  In  a  large 
proportion  of  cases  the  preparations  of  mercury  are  not  well  borne 
by  the  stomach.  It  is  probably  better,  therefore,  as  a  rule,  to 
use  inunctions  of  mercury,  using  one  dram  of  blue  ointment  daily, 
as  follows :  The  patient  should  first  take  a  warm  bath,  then  have 
the  mercury  well  rubbed  in  over  the  inner  surface  of  the  forearm 
and  arm,  the  axilla  and  along  the  side  of  the  chest,  for  fifteen  min- 
utes. A  shirt,  kept  for  this  purpose,  should  be  put  on  next  the 
skin,  and  the  ordinary  clothing  worn  over  this ;  the  next  night  the 
opposite  arm  and  side  of  the  body  should  be  the  seat  of  inunction  ; 
next,  the  right  groin  and  inner  surface  of  the  right  thigh;  next, 
the  same  regions  of  the  opposite  side  of  the  body;  finally,  the 
anterior  surface  of  the  chest  and  abdomen.  The  object  of  chang- 
ing about  is  to  avoid  irritation  of  the  skin  (Hare).  Instead  of 
blue  ointment  the  oleate  of  mercury  (10  per  cent.)  may  be  used. 
At  the  same  time  let  the  patient  take  by  the  mouth  15  grains 
(.97  gm.)  of  iodide  of  potassium,  in  milk,  three  times  a  day  after 
meals.  This  treatment  should  be  carried  out  during  the  whole 
of  pregnancy  and  for  a  long  time  after. 

GONORRHCEA 

Gonorrhoea  is  in  many  ways  sadly  interesting  from  an 
obstetrical  standpoint.  On  account  of  the  hyperaemia  of  the 
pelvic  tissues  acute  gonorrhoea  during  pregnancy  is  generally  of 
a  very  severe  type  and  sometimes  assumes  almost  a  malignant 
character. 

Diagnosis. — The  chief  symptoms  are  painful  micturition  and 
purulent  discharge  from  the  vagina,  a  burning  pain  in  the  urethra 
with  frequent  micturition  and  also  burning  pain  in  the  vulva  and 
vagina.  The  nature  of  the  gonorrhceal  discharge  is  probably  not  so 
well  understood  as  it  should  be  by  general  practitioners.  All  preg- 
nant women  have  more  or  less  vaginal  discharge  which  we  call 
leucorrhoea.  One  may  learn  a  good  deal  as  to  the  nature  of  the 
discharge  by  asking  two  or  three  simple  questions.  What  is  the 
color?  Is  it  fetid  or  offensive  in  character?  If  it  is  white  and 
does  not  stain  the  linen  one  may  conclude  that  it  is  the  ordinary 
leucorrhoea  of  pregnancy.  If  it  is  yellow  and  fetid  one  should 
suspect  that  an  abscess,  such  as  pyosalpinx,  an  ovarian  abscess,  or 


270     INTEECUKEENT    DISEASES    OF    PEEGNANCY 

a  suppurative  ovarian  cyst,  has  ruptured  into  the  upper  part  of  the 
vagina.  If  there  is  a  yellow  or  greenish  discharge,  which  is  not 
perhaps  fetid  but  slightly  offensive,  it  is  usually  due  to  gonorrhoea. 
A  yellow  purulent  discharge,  slightly  offensive,  from  the  vagina 
and  urethra,  with  burning  and  painful  micturition,  will  nearly 
always  indicate  the  existence  of  gonorrhoea.  The  discovery  of 
the  presence  of  the  gonococcus  will,  of  course,  make  the  diagno- 
sis certain.  Bartholin's  glands  are  generally  involved.  Further 
references  as  to  the  way  it  spreads  are  made  in  another  chapter 
(see  page  476). 

Treatment. — This  should  be  carefully  carried  out  in  a  thorough 
manner  in  order  to  cure  the  disease  as  soon  as  possible  and  also  to 
prevent  the  terrible  sequelae  which  are  apt  to  follow.  To  order 
a  woman  to  use  an  antiseptic  douche  is  almost  useless.  Even 
the  most  thorough  kind  of  douching,  with  the  woman  lying  on 
her  back,  is  generally  not  sufficient.  The  ridges  and  folds  in  the 
vaginal  mucous  membrane  prevent  the  solution  from  properly 
cleansing  it. 

One  should  keep  the  patient  in  bed,  keep  the  bowels  open  with 
Epsom  salts,  restrict  the  diet,  and  employ  vigorous  local  treatment. 
Davis's  method,  as  given  in  his  text-book  (first  edition),  is  an  ex- 
cellent one.  His  description  of  it  is  as  follows :  Place  the  patient 
upon  her  back  across  a  table  or  bed,  and  thoroughly  douche  the 
vagina  with  a  quart  of  warm  water,  containing  an  ounce  of  the 
tincture  of  green  soap,  or  two  quarts  of  castile  soap-suds.  The 
purpose  of  this  cleansing  douche  is  to  remove  the  pus  and  mucus 
which  cover  the  mucous  membrane  and  harbor  gonococci.  To  do 
this  cleansing  properly  it  may  be  necessary  to  use  a  rubber  specu- 
lum, often  a  round  speculum  is  most  convenient ;  the  vagina  should 
then  be  thoroughly  irrigated  with  a  solution  of  bichloride  of  mer- 
cury, 1 :  1000.  Absorbent  cotton  should  be  taken  in  a  pair  of  for- 
ceps, or  wrapped  upon  an  applicator,  and  the  interior  of  the  cervix 
thoroughly  but  gently  cleansed  with  mercurial  solution.  When  this 
has  been  done  the  urethra  should  be  inspected  and  wiped  out  for  an 
inch  or  more  in  its  extent  in  the  same  manner.  This  must  be  fol- 
lowed by  a  douche  of  simple  warm  water.  The  vagina  is  then  tam- 
poned with  gauze  containing  50  per  cent,  of  iodoform,  the  external 
parts  should  be  thoroughly  washed  with  soap  and  water,  then 
rinsed  with  water  and  douched  with  a  bichloride  solution,  1 :  1000. 
A  dressing  of  bichloride  gauze,  1 :  2000,  over  the  vulva  is  kept  in 


GONOREHCEA  271 

position  by  a  T  bandage.  This  thorough  cleansing  should  be  re- 
peated daily  until  the  disorder  grows  perceptibly  better. 

As  the  disinfection  of  the  vulva  and  vagina  is  a  very  painful 
operation,  it  should  always  be  done  under  an  ana3sthetic.  Other- 
wise it  is  impossible  to  do  the  cleansing  efficiently. 

The  greatest  care  must  be  taken  to  have  the  patient  pass  her 
urine  without  the  use  of  a  catheter  on  account  of  the  danger  of 
infecting  the  bladder.  As  soon  as  the  discharge  ceases  to  be  puru- 
lent and  becomes  mucoid,  the  douche  of  mercurial  solution  should 
give  place  to  lysol,  2  per  cent.,  or  carbolic  acid,  2  per  cent.  Should 
cystitis  occur  the  bladder  must  be  washed  out  two  or  three  times 
in  twenty-four  hours  with  lysol,  1  per  cent.,  or  saturated  solution 
of  boric  acid.  It  is  also  well,  in  these  cases,  to  give  the  patient  boric 
acid,  or  uro tropin,  internally  if  fever  is  present.  For  the  chronic 
gonorrhoea,  which  is  unsuspected  by  the  patient,  vaginal  irrigation 
with  lysol,  2  per  cent.,  and  tincture  of  green  soap  may  be  carried 
on  by  the  patient  herself  several  times  daily,  until  the  discharge 
ceases.     The  following  formula  is  useful : 

Lysol !ij; 

Tincture  of  green  soap : §  iv. 

A  teaspoonful  in  a  quart  of  warm  water  as  vaginal  douche,  night 
and  morning. 

The  worst  case  of  gonorrhoea  that  I  have  seen  was  in  a  patient 
infected  about  two  weeks  before  labor.  I  treated  her  daily  for 
eight  days  before  confinement,  first  douching  with  lysol  solution, 
then  applying  a  solution  of  nitrate  of  silver,  30  grains  to  the 
ounce,  through  a  Ferguson's  circular  speculum.  Douches  were 
continued  daily,  sometimes  using  lysol,  sometimes  protargol.  The 
discharge  was  very  much  diminished,  but  the  patient  was  by  no 
means  cured  when  labor  came  on.  Healthy  child ;  no  ophthalmia. 
In  spite  of  careful  treatment  after  labor  the  disease  spread  to  the 
Fallopian  tubes  or  past  them,  causing  localized  peritonitis. 

When  a  patient  refuses  to  submit  to  efficient  local  treatment 

Eden  uses  medicated  vaginal  pessaries,  a  favorite  one  being  a 

pessary  made  of  gelatine,  or  ordinary  cocoa  butter,  containing  20 

grains  of  iodoform  and  10  minims  of  oil  of  eucalyptus.     This  can 

be  passed  into  the  vagina  when  the  patient  goes  to  bed.     It  melts 

and  the  solution  flows  over  the  vaginal  walls  and  into  the  folds 

and  depressions.     Douches  should  be  used  in  addition. 
19 


CHAPTER  XIII 
DISEASES  OF  PREGNANCY  AND   THE  PUERPERIUM 

DISEASES  OF  THE  KIDNEYS 

Pathological  Conditions. — The  following  pathological  conditions 
of  the  kidneys  may  be  found  during  pregnancy:  1,  The  toxsemic 
kidneys  of  pregnancy ;  2,  acute  nephritis  arising  during  pregnancy ; 
3,  chronic  nephritis  with  pregnancy. 

Toxcemic  Kidneys.  Ley  den,  who  speaks  of  '^  the  kidneys  of 
pregnancy/'  as  if  pregnancy  always  produced  pathological  con- 
ditions in  the  kidneys,  says  the  condition  is  not  a  true  nephritis,  but 
simply  an  ansemia  of  the  kidneys  which  leads  to  fat  infiltration  in 
the  epithelium,  especially  of  the  convoluted  tubes.  There  is  a  func- 
tional disturbance  produced  by  the  pregnancy,  which  disappears 
after  the  termination  of  pregnancy.  The  symptoms,  which  are 
likely  to  appear  in  the  second  half  of  pregnancy,  are  dropsy  and 
albuminuria.  The  urine  is  deficient  in  quantity  and  contains,  in 
addition  to  albumin,  cylinder  casts,  renal  epithelium,  and  white 
and  red  blood  corpuscles.  Eclampsia  is  apt  to  occur.  This  is  a 
good  description  of  a  condition  usually  found  in  connection  with 
the  general  systemic  toxsemia  of  pregnancy,  but  not  commonly 
present  in  the  kidneys  during  normal  pregnancy.  The  word 
toxaemic  as  applied  to  the  kidneys,  under  such  circumstances,  will 
give  us  a  better  conception  of  their  true  condition. 

Nephritis  arising  during  Pregnancy.  The  general  health  is  more 
affected  than  in  the  toxsemic  kidneys  of  pregnancy.  Hypertrophy 
of  the  heart  is  soon  produced  (earliest  in  about  six  weeks) .  Reti- 
nitis and  cerebral  haemorrhage  may  occur  in  the  later  stages. 

Chronic  Nephritis  with  Pregnancy.     The  symptoms  are  similar 
to  those  due  to  nephritis  arising  during  pregnancy,  but  are  apt 
to  be  more  severe.     Uraemia,  without  convulsions,  may  occur  in 
either  case,  but  eclampsia  is  rare. 
272 


DISEASES    OF    THE    KIDNEYS  273 

SYMPTOMS   OF  NEPHRITIS 

Albuminuria.  Albumin  is  found  in  the  urine  of  women  during 
pregnancy  in  from  5  to  10  per  cent,  of  the  cases.  Albuminuria  is  a 
symptom  of  great  importance ;  but  it  is  only  a  symptom  of  a  disease 
and  not  the  disease  itself.  By  some  the  term  has  been  applied  to 
that  diseased  condition  of  the  system  which  gives  rise  to  eclampsia. 
During  the  last  few  years  the  term  general  toxaemia  of  pregnancy 
has  been  used  for  this  poisoning,  which  affects  various  organs,  or 
perhaps  all  the  tissues  of  the  body.  We  shall  consider  albuminuria 
a  symptom  of  some  local  condition  of  kidneys  which  may  or  may 
not  have  existed  before  pregnancy,  or  a  symptom  of  general  toxae- 
mia with  kidney  disease  or  kidney  insufficiency. 

Many  theories  have  been  advanced  as  to  the  cause  of  albumi- 
nuria peculiar  to  pregnancy,  such  as  the  following:  obstruction  of 
ureters  by  pressure  of  the  gravid  uterus ;  increased  work  thrown 
on  the  kidneys  by  the  addition  to  the  blood  of  foetal  waste  prod- 
ucts ;  increased  arterial  pressure  of  pregnancy ;  pressure  of  uterus 
on  renal  veins ;  action  of  a  special  form  of  micrococcus.  Theoriz- 
ing upon  this  subject  is  interesting,  but  these  "causes"  are  mostly 
mere  conjectures. 

The  presence  of  albumin  may  be  due  to  a  leucorrhceal  discharge 
which  is  added  to  the  urine.  To  clear  up  any  doubt  it  may  be 
necessary  to  withdraw  some  urine  by  catheter.  As  there  is  always 
some  danger  in  catheterization,  in  spite  of  antiseptic  precautions, 
it  may  be  well  to  order  the  patient  to  use  a  vaginal  douche  and 
then  insert  into  the  lower  part  of  the  vagina  a  small  tampon  of  ab- 
sorbent cotton  with  a  string  attached,  before  urinating.  It  is  also 
probable  that  traces  of  albumin  may  be  due  to  a  slight  catarrh  of 
the  bladder,  which  is  not  unusual  in  pregnancy.  The  urine  should 
always  be  filtered  to  exclude  cellular  sources  of  albumin  before 
testing  for  that  substance. 

When  albuminuria  is  found  early  in  pregnancy  it  is  generally 
due  to  nephritis.  When  it  appears  in  the  seventh,  eighth,  or  ninth 
month  of  gestation  it  is  usually  due  to  a  general  toxaemia,  with 
which  there  is  generally  associated  the  toxsemic  kidneys  of  preg- 
nancy. There  is  an  impression  very  largely  entertained  that  early 
albuminuria  indicates  a  strong  probability  that  the  patient  will 
have  what  is  commonly  known  as  puerperal  eclampsia ;  or,  to  put 
it  in  another  way,  early  acute  nephritis,  or  chronic  nephritis  which 


274     PEEGNANCY  AND  THE  PUEEPEEIUM 

existed  before  pregnancy,  is  likely  to  cause  convulsions.  Such  an 
opinion  is  not  correct.  Nephritis  does  not,  as  a  rule,  cause  eclamp- 
sia, although  it  somewhat  frequently  causes  ursemia  without  con- 
vulsions (as  mentioned,  p.  272). 

The  Urine. — It  is  unnecessary  to  say  much  about  the  casts  in 
the  urine,  and  the  increase  or  decrease  in  quantity  under  the  differ- 
ent conditions  which  may  exist.  In  acute  nephritis,  as  in  the 
toxsemic  kidneys  of  pregnancy,  the  urine  is  scanty  and  at  times 
suppressed.  It  is  smoky  and  has  a  high  specific  gravity,  contains 
a  large  quantity  of  albumin,  hyaline,  blood,  and  epithelial  casts, 
free  blood,  and  epithelial  cells.  In  chronic  parenchymatous 
nephritis  (large  white  kidney)  the  urine  is  generally  diminished, 
although  it  is  sometimes  normal  in  color  and  in  appearance;  it 
contains  much  albumin,  together  with  hyaline,  fatty  and  granular 
casts,  and  fatty  epithelial  cells.  In  chronic  interstitial  nephritis 
(contracted  kidney)  the  urine  is  increased  in  quantity,  pale  in 
color,  has  low  specific  gravity,  contains  only  a  trace  of  albumin  and 
a  few  narrow  hyaline  casts.  It  occasionally  happens  that  a  chronic 
interstitial  nephritis  is  complicated  by  a  more  or  less  acute  tubal 
nephritis.  In  such  an  event  the  urine  would  probably  be  dimin- 
ished in  quantity,  and  would  contain  an  increased  amount  of  albu- 
min and  some  blood. 

(Edema. — Dropsy,  often  seen  in  the  face,  is  an  ordinary  symp- 
tom of  acute  or  chronic  parenchymatous  nephritis  and  frequently 
appears  early  in  pregnancy,  while  the  oedema  due  to  the  ordinary 
toxsemic  kidneys  generally  appears  in  the  latter  part  of  pregnancy. 

Affections  of  the  Eyes. — Affections  of  the  eyes  are  very  com- 
monly due  to  chronic  interstitial  nephritis,  but  also  frequently  to 
the  general  toxaemia  accompanying  the  kidneys  of  pregnancy. 
These  affections  are  chiefiy  retinal  hsemorrhages  and  white  spots  of 
retinitis,  with  which  are  associated  dimness  of  vision,  the  sensation 
of  spots  floating  before  the  eyes,  etc.  The  following  report  shows 
that  recovery  may  follow  serious  retinitis : 

Mrs.  B.,  primipara,  aged  forty,  twin  pregnancy.  During  pregnancy 
had  serious  toxsemia,  the  chief  symptoms  being  headache,  disorders  of 
vision,  albuminuria  and  oedema.  On  second  day  after  labor  had  a  con- 
vulsion, recovered  consciouness  in  ten  or  twelve  hours.  Could  distinguish 
light  from  darkness  but  had  no  further  vision.  Examined  by  Dr.  Mac- 
lennan  on  fourteenth  day  after  convulsion.  Report :  Retina  oedematous, 
numerous  scattered  flame-shaped  haemorrhages  extending  over  the  whole 


DISEASES    OF    THE    KIDNEYS  275 

retina,  but  smaller  toward  the  pcnj)hory.  Optic  disk  swollen,  outline 
indistinct.  Patient  can  count  finders  and  see  letters,  but  not  read  them. 
Photophobia.  Report  of  examination  on  thirty-fifth  day:  Can  read 
and  see  well,  although  there  is  still  some  photophobia.  (Edema  of 
the  retina  has  subsided.  Disk  distinct.  Haemorrhages  absorbing  and 
decolorizing. 

Other  Symptoms. — Other  symptoms  which  may  be  mentioned 
are  increased  arterial  tension,  headache,  sleeplessness,  dizziness, 
vomiting,  ansemia,  and  convulsions. 

Prognosis. — Chronic  Bright's  disease  is,  of  course,  very  serious 
at  any  time ;  and,  unfortunately,  is  generally  greatly  aggravated  by 
pregnancy.  This  is  especially  the  case  when  a  more  or  less  acute 
tubal  nephritis  is  added  to  the  preexisting  interstitial  nephritis.  I 
have  referred  to  some  of  the  dangers  of  nephritis  of  pregnancy. 
Among  others  that  I  have  not  mentioned  are  various  forms  of 
paralysis  which  may  be  produced  by  rupture  of  a  cerebral  vessel  or 
as  a  result  of  urcemia,  such  as  paraplegia,  hemiplegia,  and  facial 
paralysis.  The  dangers  are  increased  in  every  way  when  the 
patient  is  half  starved  by  being  placed  on  an  exclusive  milk  diet. 
There  may  be  some  excuse  for  prescribing  this  diet  in  the  acute 
disease.  It  may  do  good  if  continued  for  only  a  short  time.  I 
desire  to  express  a  very  positive  opinion  that  a  pregnant  woman 
with  granular  kidneys  requires  good  food. 

In  chronic  nephritis  of  pregnancy  abortion,  or  premature  labor 
with  a  still-born  child,  is  very  apt  to  occur.  This  is  generally  due 
to  the  prior  death  of  the  foetus  or  child.  In  a  certain  proportion  of 
cases,  however,  the  child  is  born  alive  and  well.  Ordinary  acute 
nephritis  may  occur  during  pregnancy,  but  not  so  frequently  as 
supposed  by  some.  With  all  forms  of  nephritis  there  is  associated 
grave  danger  to  the  foetus.  In  a  certain  (rather  small,  I  think) 
proportion  of  cases,  acute  nephritis  may  be  transformed  to  one  of 
the  forms  of  chronic  nephritis. 

Pregnancy  in  a  woman  suffering  from  chronic  nephritis  should 
always  cause  anxiety;  not  because  the  disease  of  the  kidneys  is 
likely  to  cause  eclampsia,  but  because  the  pregnancy  is  likely  to 
increase  the  perils  to  which  the  patient  is  exposed  from  the  pres- 
ence of  nephritis. 

Should  abortion  be  induced  in  a  patient  with  chronic  nephritis  ? 
This  question  is  frequently  asked,  and  the  answer  given  by  some  is 
■^yes.     My  own  answer  is — no.     I  am  fully  aware  that  in  giving 


276     PEEGNANCY  AND  THE  PUEEPEEIUM 

such  an  answer  I  am  assuming  a  serious  responsibility ;  but  at  the 
same  time  I  am  acting  under  a  firm  conviction  that  this  very  serious 
operation,  involving  as  it  does  the  deliberate  destruction  of  a 
human  life,  should  never  be  performed  unless  the  mother's  life  is 
absolutely  and  immediately  endangered.  The  following  case  will 
illustrate  my  position : 

Mrs.  A.  Seen  in  consultation  with  Dr.  W.  P.  Caven  in  May,  1895. 
Pregnant.  Advanced  two  months.  Attended  in  confinement  a  few 
years  before  by  the  late  Dr.  Carson.  Had  eclampsia.  After  a  very  serious 
illness,  recovered,  but  with  chronic  Bright's  disease  (I  do  not  know  when 
contracted).  In  her  next  pregnancy  Dr.  Carson,  a  most  competent  ob- 
stetrician, induced  abortion,  at  the  same  time  telling  her  that  it  was  im- 
possible to  go  through  pregnancy.  After  considering  the  case,  with  this 
history  and  with  serious  symptoms  of  toxaemia,  including  albuminuria 
and  casts,  we  induced  abortion.  Saw  her  again  in  February,  1896. 
Pregnant  a  little  more  than  two  months.  Had  albuminuria  and  some 
other  symptoms  of  toxaemia.  Decided  to  put  her  on  purgative  and  tonic 
treatment  and  to  watch  carefully.  Dr.  Caven  carried  this  out,  and 
patient  got  on  fairly  well.  Was  present  at  labor,  August  6th,  for  the 
purpose  of  assisting  in  case  of  accident.  Normal  labor  with  delivery  of  a 
healthy  child. 

In  this  case  I  gave  certain  advice  with  considerable  reluctance 
and  much  fear  and  trembling.  In  carrying  out  a  line  of  treatment 
to  a  large  extent  in  the  interests  of  the  unborn  child  it  is  necessary 
to  proceed  with  the  greatest  possible  care,  and  at  the  same  time 
watch  the  effects  on  the  patient.  If  serious  symptoms  do  not  ap- 
pear the  patient  may  be  allowed  to  go  on  to  full  term ;  if  in  spite  of 
our  well-directed  efforts  serious  symptoms  do  appear  and  do  not 
yield  to  treatment,  the  patient's  life  becomes  endangered  and  the 
pregnancy  must  be  terminated.  One  should  not  wait  too  long  and 
should  be  careful  not  to  allow  the  patient  to  become  too  much 
enfeebled  before  deciding  on  active  interference. 

Another  question  sometimes  asked  is :  ' '  Should  premature  labor 
be  induced  during  the  eighth  or  ninth  month  of  pregnancy  if 
serious  symptoms  arise  ?  "  I  have  fewer  scruples  about  the  in- 
duction of  labor,  but  never  recommend  it  until  other  treatment 
has  been  tried.  I  shall  refer  to  a  case  which  I  reported  to 
the  Toronto  Medical  Society  some  years  ago : 

Mrs.  C,  aged  twenty-seven.  Admitted  to  the  Burnside  Hospital  Octo- 
ber 3,  1893.     Supposed  to  be  in  seventh  month  of  pregnancy.     Previous 


DISEASES    OF    THE    KIDNEYS  277 

history  of  nephritis.  Had  (h-opsy,  headache,  and  affected  vision.  Urine 
loaded  with  albumin,  and  containinji;  many  casts.  Maf^nesium  sulphate 
administered.  One  week  after  admission  had  two  convulsions  at  4  and 
6  A.  M.  Treated  with  chloroform,  morphine  hypodermically,  and  chlo- 
ral per  rectum.  Symptoms  two  days  after  very  serious;  urine  loaded 
with  albumin — became  absolutely  solid  on  heating.  Examination  by 
Dr.  Hill  showed  numerous  casts,  mostly  granular  in  character,  and  a 
diminution  in  urea  excreted,  being  at  one  time  reduced  to  an  amount  a 
little  more  than  half  the  normal  quantity.  There  was  no  dilatation  of 
the  os;  cervix  partly  intact.  Condition  so  low  that  I  was  afraid  to  induce 
labor.  General  condition  improved  sHghtly  under  purgative  and  support- 
ing treatment.  Seen  by  Dr.  Temple,  who  advised  induction  of  labor.  I 
concurred,  but  decided  to  wait  till  the  following  morning,  when  I  found 
her  so  much  improved  that  I  again  postponed  operation.  She  continued 
to  improve  daily  until  October  22d,  nineteen  days  after  admission  and 
twelve  days  after  convulsions,  when  labor  commenced  and  progressed 
favorably.     Babe  still-born.     Patient  made  a  good  recovery. 

I  shall  give  no  positive  opinion  as  to  the  line  of  treatment  car- 
ried out  in  this  case.  I  give  the  history  to  show  that  a  patient 
in  an  exceedingly  critical  condition,  under  the  eliminative  treat- 
ment, may  recover  without  artificial  interference  in  terminating 
pregnancy. 

In  conclusion,  it  may  be  said  that  the  prognosis  is  not  neces- 
sarily bad,  but  the  conditions  involve  serious  dangers  and  require 
very  watchful  care. 

Morbid  Anatomy. — It  is  not  my  intention  to  refer  in  detail  to  the 
pathological  aspect.  In  acute  nephritis  the  kidneys  are  swollen 
with  non-adherent  capsules,  at  first  dark  red  in  color  but  soon  be- 
coming pale  and  mottled  in  appearance.  The  epithelium  of  the 
tubules  and  glomeruli  is  the  seat  of  what  is  called  cloudy  swelling, 
and  later  of  fatty  degeneration,  while  the  tubules  themselves  are 
blocked  with  desquamated  epithelium,  blood  corpuscles  and  an 
albuminous  exudate.  The  interstitial  tissue  is,  to  some  extent, 
infiltrated  with  leucocjdes.  In  chronic  parenchymatous  nephritis 
the  kidneys  are  at  first  large  and  pale,  while  the  tubes  are  filled 
with  fatty  epithelium  and  casts,  and  there  is  some  increase  of  the 
interstitial  connective  tissue;  later  the  kidneys  are  small,  pale, 
with  roughened  surfaces  and  capsules  more  or  less  adherent.  In 
chronic  interstitial  nephritis  the  kidneys  are  small,  red  in  color, 
with  granular  surfaces  and  adherent  capsules.  The  cortical  sub- 
stance is  greatly  reduced  in  thickness.     The  increased  connective 


278     PEEGKAKCY  AND  THE  PUEEPEKIUM 

tissue,  after  contraction  has  narrowed  the  lumen  of  the  tubules, 
causes  fatty  degeneration  and  desquamation  of  the  epithehum. 
In  amyloid  kidneys  the  organs  are  large  and  pale,  while  the  walls 
of  the  blood-vessels  are  thickened  and  infiltrated  with  wax-Uke 
material. 

Treatment. — In  all  forms  of  nephritis  with  pregnancy  our  chief 
aim  should  be  to  keep  the  bowels  open.  If  I  were  hmited  to  only 
one  medicine  I  would  certainly  choose  Epsom  salts.  There  should 
be  frequent  and  copious  watery  evacuations,  especially  in  acute 
nephritis — say  from  two  to  six  evacuations  in  twenty-four  hours 
for  acute  nephritis,  and  one  to  three  evacuations  per  day  for  chronic 
nephritis.  It  is  better  to  give  the  saturated  solution  of  Epsom 
salts,  two  to  six  drams,  three  times  a  day.  Occasionally,  in  treat- 
ing nephritis  during  pregnancy,  it  is  well  to  administer  calomel,  as 
before  directed,  to  be  followed  by  sahne  cathartics.  Do  not  give 
much  calomel  for  certain  forms  of  nephritis,  especially  the  chronic 
interstitial  form. 

I  shall  not  refer  in  detail  to  waxy  degeneration,  because  that 
condition  is  generally  added  to  the  lesions  of  contracted  kidneys  in 
cases  of  prolonged  suppuration,  syphihs,  or  tuberculosis;  it  does 
not  generally  caU  for  any  treatment  beyond  that  adopted  for  the 
chronic  interstitial  nephritis. 

In  the  acute  form,  whether  exudative  or  diffuse,  the  treatment 
should  be  prompt  and  vigorous.  Here,  the  administration  of 
calomel  followed  by  sahne  cathartics,  together  with  rest  in  bed, 
will  frequently  accomphsh  much  good.  The  skin  should  be  kept 
active  with  warm  or  hot  baths,  not  hot  packs,  and  perhaps  a  cer- 
tain amount  of  skin  friction.  Apphcations  of  hot  poultices,  or  wet 
or  dry  cups,  to  the  lumbar  region  may  be  of  service.  If  cerebral 
symptoms,  due  to  contractions  of  the  arteries,  with  labored  heart 
action,  appear,  give  arterial  dilators,  such  as  chloral,  aconite,  or 
nitroglycerin.  Nitroglycerin,  or  glonoin,  or  trinitrin  accelerates 
the  pulse,  relaxes  the  arteries  and  produces  a  feeling  of  fulness  ail 
over  the  body,  with  sometimes  severe  headache  which  may  last 
several  hours.  Care  should  always  be  used  in  administering  it, 
and  the  sad  mistake  of  giving  it  when  the  arterioles  are  relaxed 
should  never  be  made.  I  have  seen  such  a  mistake  on  more  than 
one  occasion;  and  not  long  ago  saw  a  patient  who  was  taking  it 
while  her  pulse  was  soft  and  extremities  almost  bathed  in  cold  per- 
spiration.    Nitroglycerin,  or  certain  of  the  nitrites,  especially  ni- 


DISEASES    OF    THE    KIDNEYS  279 

trite  of  amyl,  is  more  frequently  indicated  in  chronic  nephritis, 
particularly  when  there  is  uraemia  accompanied  with  contracted 
arteries.  Bloodletting,  under  such  circumstances,  is  frequently 
followed  by  very  happy  results.  When  tension  is  low,  with  feeble 
heart,  give  stimulants  such  as  caffeine,  digitalis,  strophanthus,  and 
strychnine. 

Diuretics  should  be  used  with  caution.  Most  medicines  usually 
included  in  that  class  should  not  be  used  at  all.  Water  is  the 
best  diuretic  in  these  cases  and  should  be  taken  freely.  It  has 
been  observed  by  many  clinicians  that  small  doses  of  calomel  and 
blue  pill  frequently  act  as  diuretics.  An  old-fashioned  combina- 
tion for  dropsy  is  that  of  digitalis,  squill,  and  blue  pill.  Certain  of 
the  vascular  and  cardiac  tonics,  which  raise  the  blood  pressure  and 
which  are  used  in  certain  conditions  associated  with  nephritis,  are 
diuretics  up  to  a  certain  point;  but,  as  pointed  out  by  Lauder 
Brunton,  if  pushed  too  far  they  may  cause  contraction  of  the  capil- 
laries or  arterioles.  When  this  contraction  occurs  in  the  kidneys 
the  secretion  of  urine  may  be  seriously  lessened  or  completely 
stopped.  Such  medicines  as  digitalis,  strophanthus,  sparteine, 
although  useful,  as  already  indicated,  for  weak  heart  with  low  ten- 
sion, should  be  administered  with  caution.  The  best  and  safest 
way  to  help  lame  kidneys  is  to  flush  them  with  water,  and  act  freely 
on  the  bowels  with  saline  cathartics. 

It  is  frequently  or  usually  desirable  to  give  tonics,  such  as  qui- 
nine, strychnine,  mineral  acids,  and  vegetable  bitters.  Basham's 
mixture,  or  solution  of  iron  and  ammonium  acetate,  is  so  .eminently 
respectable  that  I  dishke  to  say  anything  against  it,  but  I  shall  not 
advise  any  person  to  use  it.  I  object  strongly  to  the  indiscriminate 
use  of  the  various  forms  of  iron  in  the  different  varieties  of  neph- 
ritis.    Iron  should  not  be  prescribed  when  there  is  a  foul  tongue. 

A  few  words  as  to  diet.  For  acute  nephritis  let  the  patient  take 
as  little  food  and  as  much  water  as  possible  for  some  days.  An 
exclusive  milk  diet  is  probably  better  than  a  mixed  diet  containing 
considerable  quantities  of  meats  and  other  nitrogenous  foods,  but 
I  never  prescribe  it.  The  patient  may  choose  from  the  following  : 
Acid  fruits,  green  vegetables — especially  spinach  and  lettuce — 
bread,  toast,  rice,  tapioca,  sago,  milk  diluted  with  ordinary  or 
mineral  water,  buttermilk,  kumiss,  tea,  lemonade,  water,  mineral 
waters.     After  a  time  I  should  add  fish  and  potatoes. 

For  chronic  nephritis,  especially  interstitial  nephritis,  the  pa- 


280    PEEGNANCY  AND  THE  PUEEPEEIUM 

tient  may  choose  from  the  following :  Limited  amounts  of  meats 
and  poultry,  fish,  oysters,  apples,  peaches,  oranges,  lemons,  grape 
fruit,  cherries,  currants,  etc.,  spinach,  lettuce,  cabbage,  cauliflower, 
celery,  rhubarb,  green  corn  on  the  cob,  carrots,  bread,  toast, 
crackers,  potatoes,  a  little  pepper,  salt,  and  vinegar  for  flavoring 
purposes,  oatmeal,  corn-meal,  rice,  sago,  tapioca,  macaroni,  vermi- 
celli, and  all  beverages  recommended  for  the  acute  disease. 

The  patient  should  avoid  animal  soups  and  broths,  eggs, 
cheese,  baked  beans,  asparagus,  sweet  potatoes,  turnips,  syrup, 
beets,  honey,  ice-cream,  sweets;  sweet  fruits,  such  as  grapes, 
bananas,  raisins,  pears,  all  canned  fruits  preserved  in  sugar ;  cham- 
pagne, cider,  port  wine,  burgundy,  claret,  sherry,  beer,  porter,  all 
sweet  mnes. 

The  following  special  instructions  may  be  given  to  the  patient : 
1,  Eat  in  moderation;  2,  keep  the  bowels  open ;  3,  may  eat  meat 
or  poultry  three  times  a  week ;  4,  may  try,  once  a  week  or  once  a 
fortnight,  a  meal  without  any  restrictions  as  to  quality  of  food,  but 
still  eating  in  moderation.  At  the  same  time  avoid  foods  which 
in  the  past  have  disagreed  with  the  patient. 

Surgical  Treatment  of  Nephritis.— According  to  Reginald  Har- 
rison, the  hsematuria,  pain,  and  suppression  of  urine,  which  some- 
times occur  in  nephritis,  are  due  to  tension  within  the  tough  renal 
capsule.  This  tension  occasionally  leads  to  a  slow  extravasation 
of  urine  into  the  renal  tissue,  which  is  highly  destructive.  To  re- 
lieve such  tension  he  performed  a  nephrotomy — either  puncture 
or  splitting  of  the  kidney.  For  the  same  purpose  Edebohls  per- 
formed a  renal  decapsulation — removing  the  fibrous  capsule  of  the 
kidney.  Primrose,  Peters,  and  Fenton,  of  Toronto,  have  also  per- 
formed this  operation.  The  results  have  been  fairly  encouraging. 
Some  surgeons  think  that  the  removal  of  the  capsule,  which  is  a 
barrier  to  collateral  circulation,  promotes  a  free  flow  of  blood 
through  the  kidney.  In  consequence  the  increased  interstitial 
tissue  is  absorbed,  pressure  on  tubules  is  removed,  and  a  regenera- 
tion of  the  renal  epithelium  takes  place. 

DISEASES    OF  THE  BLADDER 

Irritability  of  the  Bladder. — This  is  very  common,  especially  in 
the  early  months  of  pregnancy  as  the  uterus  enlarges.  The  un- 
pleasant symptoms  connected  with  this  condition  generally  be- 


DISEASES    OF    THE    BLADDER  281 

come  less  annoying  about  the  fourth  month,  although  more  or  less 
frequency  of  micturition  is  common  during  the  whole  of  pregnancy. 
In  the  latter  eight  or  ten  weeks  the  uterus  has  so  greatly  increased 
in  size  that  the  posterior  wall  of  the  bladder,  which  is  in  close  con- 
nection with  the  anterior  surface  of  the  uterus,  is  drawn  upward 
so  far  that  the  shape  is  greatly  changed,  being  elongated  and  flat- 
tened. Under  such  circumstances  the  squeezing  of  the  bladder 
between  the  abdominal  wall  and  the  anterior  uterine  surface  is  so 
great  that  frequency  of  micturition  is  almost  always  present,  and 
sometimes  is  so  extreme  as  to  cause  great  discomfort  with  impair- 
ment of  health. 

Cystitis,  or  inflammation  of  the  mucous  membrane  lining  the 
bladder,  is  rather  common  during  pregnancy.  Retention  of  urine, 
especially  when  due  to  retroversion  of  the  gravid  uterus,  is  prob- 
ably one  of  the  most  frequent  causes  of  cystitis.  It  is,  of  course, 
well  known  that  catheterization  for  the  retention  is  quite  likely  to 
produce  very  serious  cystitis  when  antiseptic  or  aseptic  precautions 
are  not  used.  Gonorrhoea  in  its  various  forms,  acute,  subacute, 
and  latent,  is  probably  more  frequently  a  cause  of  cystitis  than  is 
generally  supposed.  From  these  various  causes — probably  mostly 
from  the  different  forms  of  pressure  of  the  enlarged,  and  sometimes 
displaced,  uterus — very  severe  cystitis  is  sometimes  present.  As 
pointed  out  by  Herman,  it  may  go  on  to  sloughing  and  exfoUation 
of  the  whole  vesical  mucous  membrane;  or  it  may  produce  gan- 
grene of  the  vesical  wall  at  one  spot,  having  as  its  result  perfora- 
tion of  the  bladder.  Irritability  of  the  bladder  may  also  be 
caused  by  reflex  or  sympathetic  influences. 

Treatment. — In  speaking  of  the  treatment  I  shall  refer  to  all 
forms  of  irritability,  including  cystitis.  I  regret  that  some  authors 
have  taken  the  position  that  as  these  troublesome  affections  are 
not  preventable  they  must  simply  be  endured,  because  no  appro- 
priate treatment  is  possible.  The  tendency  of  such  teaching  is  to 
make  us  fold  our  hands  and  lapse  into  hopeless  neghgence  or  incom- 
petency. In  a  large  proportion  we  may  do  much  to  relieve,  in  all 
cases  we  may  do  something  to  diminish  suffering.  Remember, 
in  this  connection,  that  many  women,  especially  in  their  first  preg- 
nancies, hesitate  long  before  consulting  a  physician  and  explaining 
in  detail  their  ailments.  By  all  means  encourage  them  to  tell 
everything,  and  discover  all  you  can  and  then  do  what  you  can  to 
cure  or  alleviate  their  suffering.     Bland  mucilaginous  drinks,  such 


282     PEEGNANCY  AND  THE  PUEEPERIUM 

as  flaxseed  tea,  should  be  freely  given,  displacements  of  the  uterus 
should  be  corrected  and  constipation  thoroughly  treated. 

Skene's  prescription  is  suitable  for  all  forms  of  irritability  or 
subacute  or  chronic  cystitis. 

Iji,  Acid,  benzoic 3  iv ; 

Sod.  bicarb   3  ss.  ; 

Sacch.  alb 1  iv ; 

Spt.  limon gtt.  v. 

Sig. :  Triturate.  A  teaspoonful  in  water  every  three  or  four  hours. 

The  following  may  be  used: 
3   Sod.  borat 


A   .  ,  .  .     ( aa    gr.x. 

Acid,  benzoic ) 

Infus.  buchu §  i. 

Sig. :  One  dose.    Take  four  times  a  day. 

Benzoic  acid  alone  is  not  soluble  in  these  proportions,  but  when 
mixed  with  the  sodium  borate  a  decomposition  takes  place  which 
makes  it  soluble.  However,  while  soluble  in  one  ounce  of  the 
infusion,  it  would  not  be  so  in  half  an  ounce. 

Although  tincture  of  hyoscyamus  and  liquor  potassse  are  incom- 
patible, this  old-fashioned  mixture  frequently  has  a  good  effect. 

5   Tinct.  hyoscyami )  __        .    . 

Liq.  Potassse ....["'' 

Aq.  ad fij- 

Sig. :  A  teaspoonful  in  milk  three  or  four  times  a  day. 

If  pain  is  very  severe  from  acute  cystitis  give  15  minims  of  the 
tincture  of  opium  in  infusion  of  linseed  freshly  prepared.  To  each 
small  cup  of  this  add  20  to  30  minims  of  hquor  potassse. 

In  chronic  cystitis  certain  medicines  have  a  marked  effect  on 
the  character  of  the  urine.  Boric  acid  is  one  of  the  best.  When 
given  in  15-grain  doses  in  a  glass  of  water  or  milk  three  or  four 
times  a  day  it  frequently  has  a  marked  effect.  Urine  which  is 
ammoniacal  and  highly  offensive  may  be  so  changed  in  forty-eight 
hours  or  less  that  it  is  voided  clear  and  entirely  free  from  smell. 
After  some  days  the  dose  may  be  diminished  to  5  grains  three 
times  a  day.  Sometimes,  unfortunately,  it  irritates  the  stomach 
and  destroys  the  appetite.     Urotropine,  dose  5  to  15  grains  (.32 


GEN"EEAL    TOX^.MIA    OF    PRECtN"ANCY  283 

to  1  gm.)  three  times  a  day,  is  valuable  as  a  urinary  antiseptic.  A 
convenient  form  is  the  effervescent  urotropine  4  grain  tablet 
(Varalette). 

In  obstinate  cases  local  treatment  may  be  necessary.  General 
applications  may  be  made  to  the  whole  interior  of  the  bladder 
through  a  catheter,  or  limited  applications  may  be  made  through 
the  endoscope.  Washing  out  the  bladder  with  sterile  warm  water 
often  answers  a  good  purpose. 

Incontinence  of  Urine. — This  condition  may  be  treated  by  the 
use  of  the  abdominal  belt,  by  giving  tonics  (belladonna,  strych- 
nine, etc.)  and  by  advising  the  patient  to  take  a  moderate  amount 
of  fluid. 

Retention  of  Urine. — This  is  caused  by  retroversion  of  the 
uterus  in  the  early  part  of  pregnancy  and  cystocele  in  the  later  part. 
Another  cause  is  reflex  contraction  of  the  neck  of  the  bladder.  The 
treatment  is  catheterization,  with  the  most  scrupulous  aseptic  and 
antiseptic  precautions. 

Diabetes. — A  patient  with  diabetes  may  conceive  and  pass 
through  pregnancy  with  comparative  safety.  There  is,  however, 
always  some  danger  for  the  mother  and  great  danger  for  the  child 
in  utero.  The  mother  frequently  dies  shortly  after  labor.  The 
foetus  generally  dies  early  in  pregnancy.  Diabetes  may  occur  only 
during  pregnancy  and  disappear  after  labor. 

Glycosuria  occurs  in  2  to  4  per  cent,  of  pregnant  women.  Two 
kinds  of  glycosuria  are  found  : 

1.  When  the  sugar  is  lactose. 

2.  When  the  sugar  is  glucose. 

Lactosuria  is  by  far  the  more  common  variety,  and  is  not  likely 
to  cause  serious  symptoms. 

Treatment.  Carry  out  the  usual  medicinal  and  dietetic  treat- 
ment. 

Empty  the  uterus  in  extreme  cases. 

GENERAL  TOXEMIA  OF  PREGNANCY. 

Toxaemia  of  pregnancy  is  a  general  poisoning  of  the  system  b}' 
toxines  resulting  from  imperfect  eUmination,  due  to  defects  in  the 
intestines,  liver,  kidneys,  and  perhaps  other  organs. 

Ordinary  health  is  a  very  precarious  and  uncertain  thing.  To- 
day one  is  well ;  to-morrow  one  may  be  sick,  with  perhaps  a  head- 


284     PEEGNANCY  AND  THE  PUERPERIUM 

ache,  a  furred  tongue,  and  a  high  temperature.  The  cause  may- 
be from  without  or  it  may  be  from  within.  Assimilation  may  have 
gone  wrong ;  secretion  and  excretion  may  have  lost  their  balance ; 
poison  of  some  sort  may  have  come  into  existence  and  may  be 
retained ;  it  may  be  a  bilious  attack — whatever  that  is — or  it  may 
be  something  much  worse.  The  equilibrium  of  health  appears  to 
be  more  easily  disturbed  during  pregnancy  than  at  other  times. 

Modern  views  as  to  toxaemia  of  pregnancy  are  based  chiefly  on 
the  observations  of  Bouchard,  who  published  in  1887  his  ''Le9ons 
sur  les  Auto-intoxications."  He  expressed  the  opinion  that  even 
in  health  the  blood  and  other  tissues  of  the  body  contain  toxic 
substances  of  various  kinds,  partly  introduced  with  the  food  and 
partly  produced  within  the  body  itself  by  digestive  processes  and 
tissue  metabolism.  He  thought  the  condition  of  health  depended 
upon  a  properly  balanced  adjustment  of  the  production  and  ex- 
cretion of  these  toxic  substances.  When  this  balance  was  lost, 
increase  of  production,  or  diminution  of  excretion  of  toxines,  or 
both,  produced  a  condition  of  toxaemia  or  auto-intoxication.  It 
was  supposed  that  this  theory  if  correct  would  be  readily  capable 
of  experimental  proof.  A  large  amount  of  experimental  work  was 
done  with  this  end  in  view,  especially  in  France,  but  also  in  other 
parts  of  the  continent. 

An  admirable  critical  review  of  the  evidence  furnished  by  the 
large  amount  of  the  experimental  work  which  has  been  done  up  to 
1902  has  recently  been  pubhshed  by  Eden.  He  expresses  a  posi- 
tive opinion  that  proof  of  this  theory  has  not  been  obtained,  and 
never  can  be  obtained,  by  the  methods  of  investigation  hitherto 
adopted.  He  also  thinks  that  very  Httle  further  can  be  done  until 
physiological  chemistry  can  separate  definite  toxines  from  the 
blood.  He  practically  tells  us  that  normal  pregnancy  is  not 
accompanied  by  any  condition  of  the  blood  that  can  readily  be 
called  toxaemia.  In  this  respect  I  entirely  agree  with  Dr.  Eden. 
I  have  thought  for  many  years  that  all  our  considerations  of  preg- 
nancy and  labor  in  a  healthy  woman  should  be  from  a  physiological 
rather  than  from  a  pathological  standpoint ;  but  we  should  recog- 
nize as  a  fact  that  in  a  certain  minority  of  cases  diseased  conditions 
may  arise  and  may  affect  the  woman  more  or  less  seriously.  Such 
a  view,  it  seems  to  me,  corresponds  exactly  with  our  cHnical  obser- 
vations and  partly,  at  least,  with  our  post-mortem  evidences. 

Without  any  further  discussion  of  this  subject,  I  shall  assume 


GENERAL    TOXAEMIA    OF    PTIEOXAXCY  285 

that  some  wonicii  during  })r('fi;nancy  are  affected  by  certain  dis- 
eased conditions  which  are  inchided  under  the  rather  vague  term 
of  toxaiuiia.  As  a  consequence,  there  exists  one  or  more  poisonous 
substances  called  toxines  which  produce  serious  effects  in  many 
of  the  organs  and  tissues  of  the  body,  and  perhaps  to  some  extent 
in  all  the  organs  and  ti-ssues  of  the  body.  These  offending  toxines 
are  found  chiefly  in  the  blood,  liver,  and  muscles.  It  is  probable 
that  the  liver  and  intestines  are  mostly  at  fault,  but  in  a  certain 
proportion  of  cases  insufficiency  or  inefficiency  of  the  kidneys  is  a 
serious  element  in  the  disturbance. 

Symptoms. — There  can  be  no  doubt  as  to  the  great  importance 
of  the  earliest  possible  recognition  of  the  toxsemia  of  pregnancy. 
The  chief  symptoms  are:  salivation,  disorders  of  digestion,  gen- 
eral malaise,  anaemia,  nervous  disturbances  with  headache,  dis- 
orders of  vision,  etc.,  deficient  excretion  of  urine,  or  some  of  its 
constituents  (as,  for  instance,  urea),  albuminuria,  oedema,  espe- 
cially of  lower  extremities,  high  arterial  tension. 

Any  symptoms  of  the  slightest  departure  from  ordinary  health 
during  pregnancy  should  make  us  suspect  the  advent  of  general 
toxsemia,  and  should  receive  careful  investigation  and  thorough 
treatment.  If,  for  instance,  there  is  general  malaise  with  slight 
headache,  but  no  albumin  in  the  urine,  one  should  not  conclude 
that  there  is  no  toxaemia,  since  albuminuria  is  only  one  of  the 
symptoms  of  systemic  poisoning  and  sometimes  the  last  to  appear. 
Its  absence  proves  absolutely  nothing.  The  following  history  of 
a  case  will  illustrate  what  I  mean : 

About  ten  years  ago  I  attended  a  patient,  aged  twenty-three,  primip- 
ara,  somewhat  anaemic,  though  she  had  been  fairly  healthy.  No  serious 
symptoms  arose  during  pregnancy  until  the  ninth  month,  when  she  ap- 
peared to  be  slightly  ill,  had  some  malaise,  a  little  headache  for  two  or 
three  days,  and  slight  indigestion.  Found  no  trace  of  albumin  after  ex- 
amining three  specimens  of  urine,  one  the  day  before  labor.  She  had  no 
headache  the  morning  before  labor  but  seemed  rather  weak.  Labor 
progressed  favorably  through  first  stage,  when  suddenly,  to  my  amaze- 
ment, convulsions  occurred.  Delivered  immediately  with  forceps  under 
an  anaesthetic.  Expressed  placenta  at  once.  Very  little  haemorrhage. 
Patient  very  low.  Pulse  rapid  and  flickering.  Had  the  greatest  difficulty 
in  keeping  her  alive  for  next  twelve  hours;  frequently  thought  she  was 
dying.  After  twelve  hours  she  commenced  to  rally,  gained  strength 
rather  rapidly,  and  made  a  good  recovery.  Urine  examined  next  day 
and  found  to  have  a  trace  of  albumin,  which  soon  disappeared.     Child 


286     PREGNANCY  AND  THE  PUERPERIUM 

did  well  and  is  now  living  and  healthy.  This  patient  had,  I  think,  serious 
toxaemia  (without  albuminuria  or  any  sign  of  insufficiency  of  the  kidneys), 
which  I  did  not  properly  appreciate  nor  judiciously  treat. 

I  have  for  years  tried  to  emphasize  the  point  that  any  slight 
disorder,  such  as  indigestion,  malaise,  headache,  in  the  last  three 
months  of  pregnancy,  should  be  considered  a  serious  matter  and 
should  necessitate  a  very  careful  and  thorough  examination  and 
generally  some  vigorous  treatment. 

It  is  well  known  that  our  matron  in  the  Burnside  is  careful  and 
watchful.  Last  year  I  was  called  to  see  a  patient  with  eclampsia 
occurring  at  about  full  term  but  before  labor.  I  was  told  the 
patient  had  been  going  about  the  ward  as  usual  without  any  pre- 
liminary symptoms  whatever.  Finally  I  asked  this  question: 
' '  Has  this  girl  had  no  headache  during  the  last  week  ?  "  I  was  then 
told  that  she  had  a  slight  headache  the  day  before  but  was  better 
that  morning.  It  happens  that  our  patients  in  this  institution 
frequently  avoid  telling  about  slight  ailments,  such  as  headache, 
for  fear  of  having  to  take  medicines  or,  what  many  of  them  dread 
more,  of  having  their  diet  restricted. 

In  a  large  number,  if  not  in  all,  cases  of  toxaemia  of  pregnancy 
the  amount  of  urea  excreted  is  diminished.  In  the  urine  of  preg- 
nant women  without  complications  the  amount  of  urea  varies 
from  1^  to  2  per  cent.  An  amount  less  than  1  per  cent,  generally 
indicates  certain  dangers ;  why  this  is  so  I  do  not  know.  We  have 
no  direct  evidence  to  indicate  that  the  urea  produces  any  of  the 
unfavorable  symptoms,  but  clinical  observation  shows  us  that 
diminished  ureic  excretion  should  always  be  considered  a  danger 
signal,  possibly  because  the  urea  furnishes  a  standard  of  the  excre- 
tion of  other  much  more  toxic  bodies  in  the  urine. 

Although  we  should  not  give  too  much  prominince  to  albumi- 
nuria, yet  we  should  always  consider  it  a  very  serious  and,  from 
various  points  of  view,  a  very  important  symptom.  It  is  espe- 
cially serious  when  it  appears  suddenly  in  the  last  three  months 
of  pregnancy.  It  is  also  well  to  remember  in  connection  with 
albuminuria  that  there  are  two  varieties  of  precipitate,  as  pointed 
out  by  Herman.  It  is  thought  by  some  that  this  is  a  matter  of 
such  importance  as  to  form  in  certain  instances  the  best  guide  to 
prognosis.  The  two  forms  of  precipitate  are  paraglobulin  and 
serum  albumin.  According  to  Herman's  ideas,  if  the  albumin  is 
principally  paraglobulin  the  recovery  may  be  predicted  if  judicious 


GENERAL   TOXiEMIA    OF    PEEGNANCY  287 

treatment  is  carried  out,  the  patient  generally  recovering  without 
any  ill  effects.  When,  however,  serum  albumin  predominates  the 
prospects  for  recovery  are  much  less  favorable.  It  is  not  an  easy 
matter  to  separate  and  estimate  the  quantities  of  these  two  differ- 
ent sorts  of  precipitate.  According  to  Dakin  the  following  Ls  the 
best  test.  Treat  the  urine  with  a  saturated  solution  of  magnesium 
sulphate;  or  better,  saturate  the  urine  itself  with  the  salt.  This 
precipitates  the  paraglobulin  only.  The  mixture  is  then  filtered, 
and  the  residue  washed  with  a  saturated  solution  of  the  salt.  The 
paraglobulin  remains  on  the  filter ;  and  the  serum-albumin,  still  in 
solution,  is  in  the  filtrate.  This  last  can  be  precipitated  with  heat 
or  nitric  acid.  The  residue  on  the  filter  is  dissolved  in  warm,  dis- 
tilled water,  and  precipitated  again  by  heat  or  nitric  acid.  The 
relative  quantities  can  then  be  compared. 

(Edema. — This  dropsical  condition,  whether  confined  to  the 
lower  limbs  or  not,  causes  fear  in  the  minds  of  the  doctor  and 
patient.  Let  us  consider  the  matter  from  a  clinical  standpoint. 
One  patient  has  oedema  of  the  ankles ;  otherwise  she  has  no  serious 
symptoms  and  feels  well.  It  is  ascertained  by  verbal  examina- 
tion that  the  patient  had  absolutely  no  subjective  symptoms  of  a 
serious  character.  The  swelling  of  the  feet  and  ankles  is  worse  in 
the  evening,  being  very  slight  if  not  altogether  absent  before  get- 
ting out  of  bed  in  the  morning.  There  is  reason  to  think  in  such  a 
case  that  the  oedema  is  simply  due  to  pressure  of  the  gravid  uterus, 
which  prevents  a  free  return  of  the  blood  from  the  lower  extrem- 
ities. It  is  easy  to  understand  why  the  swelling  should  be  worse 
after  walking  around  through  the  day  than  it  is  in  the  morning 
after  resting  in  the  recumbent  posture.  To  leave  this  patient 
without  further  investigation,  notwithstanding  the  fact  that  the 
favorable  opinion  formed  is  probably  correct,  is  wrong.  One 
should  not  take  it  for  granted  that  this  oedema  is  a  trifling  matter 
until  he  has  exhausted  all  means  of  investigation.  One  or  more 
examinations  of  the  urine  should  be  made  in  every  instance  of 
this  sort. 

Another  patient  has  swollen  ankles ;  has  no  other  serious  symp- 
toms excepting  that  she  gets  tired  easily ;  has  no  valvular  disease 
of  the  heart,  though  palpitations  are  common ;  is  pale  and  her  lips 
are  almost  white.  The  condition  is  probably  due  to  anaemia  and 
hydrsemia,  but  again  one  or  more  examinations  of  the  urine  and 

also  of  the  blood  should  be  made. 
20 


288  PREGNAIsTCY    AND    THE    PUEEPEEIUM 

Another  patient  has  a  similar  swelling  which  has  occurred 
early  in  pregnancy,  perhaps  the  second  or  third  month.  She  was 
well  before  pregnancy,  but  now,  in  addition  to  the  oedema,  she 
has  other  slight  symptoms,  such  as  disordered  digestion,  headache, 
etc.  One  should  suspect  acute  nephritis;  an  examination  of  the 
urine  will  probably  confirm  such  suspicion.  In  another  case  these 
symptoms  may  appear  in  one  who  has  had  chronic  nephritis  be- 
fore. One  should  study  the  case  carefully  in  accordance  with  the 
directions  already  given  with  reference  to  the  different  forms  of 
nephritis.  The  probable  causes  of  such  oedema  and  accompanying 
symptoms  are :  Preexisting  kidney  disease ;  that  is,  chronic  neph- 
ritis, chronic  nephritis  with  the  condition  of  acute  nephritis  added, 
acute  nephritis,  pressure  of  gravid  uterus,  changes  in  blood  and 
heart,  reflex  disturbance  of  the  circulation. 

TREATMENT  OF  TOXEMIA 

In  speaking  of  the  treatment  I  shall  first  refer  to  diet.  What 
is  the  best  diet  ?  Tarnier  and  Charpentier  many  years  ago  told  us 
that  milk,  and  milk  only,  was  the  proper  food.  The  whole  obstet- 
rical world  accepted  their  dictum  without  any  reservation  and  for 
many  years  followed  their  advice.  At  the  same  time  physicians, 
as  well  as  obstetricians,  approved  of  milk  as  food  in  many  diseased 
conditions.  In  my  student  days  I  had  typhoid  fever,  and  I  can 
well  remember  how  much  I  suffered  for  some  weeks  in  consequence 
of  having  to  take  a  food  that  I  always  disliked.  Early  in  my  prac- 
tise, however,  notwithstanding  my  sad  personal  experience,  I  was 
still  orthodox  on  the  milk  question.  I  shall  refer  to  one  case  of 
long  continued  fever,  which  I  attended  about  twenty-two  years 
ago.  For  three  long  months  the  unfortunate  patient  got  nothing 
but  milk.  He  protested  against  such  food  at  times,  but  I  remained 
orthodox.  I  was  also  particularly  cautious,  according  to  our 
lights  in  those  days,  in  avoiding  as  far  as  possible  the  administra- 
tion of  cathartics.  At  the  end  of  three  months  we  found  a  serious 
condition  of  things.  The  lower  bowel  was  crammed  full  of  material 
very  like  hardened  plaster,  such  as  we  have  on  our  walls.  Enemata 
of  soap-suds  and  olive  oil  had  about  as  much  effect  as  though  they 
were  forced  against  a  stone  wall.  We  had  to  scoop  out  the  mass 
in  the  rectum  with  a  spoon ;  sometimes  we  had  to  fairly  drill  it  out. 
Shortly  after  this  I  found  that  milk  diet  was  the  worst  that  could 
be  devised  in  cases  of  perinseorrhaphy  and  other  operations  in  the 


GENERAL    TOX/EMIA    OF    PREG:NrANCY  289 

region  of  the  rectum.  My  experience  in  connection  with  these  and 
many  other  cases  was  so  unsatisfactory  that  I  modified  my  lines  of 
treatment  to  such  an  extent  that  I  have  not  compelled  any  patient 
to  take  an  exclusively  milk  diet  for  fifteen  years. 

Milk  Diet  for  Toxaemia  or  Albuminuria  of  Pregnancy. — In 
speaking  of  milk  diet  I  do  not  wish  to  denounce  it  altogether ;  I  be- 
lieve that  a  purely  milk  diet  is  good  for  young  children  and  calves, 
but  I  do  not  think  it  is  suitable  for  adult  human  beings.  We  have 
been  told  over  and  over  again  to  avoid  nitrogenous  foods  in  the 
albuminuria  of  pregnancy,  but  we  must  remember  that  milk  con- 
tains many  nitrogenous  substances.  Yeo,  in  his  admirable  book 
on  P^ood  in  Health  and  Disease,  shows  clearly  that  milk  alone  is  not 
a  suitable  food  for  healthy  adults,  because  it  contains  an  excess  of 
albuminates  and  fats,  and  that  it  should  be  mixed  with  other  foods, 
especially  the  carbo-hydrates.  If  it  be  conceded  that  milk  alone 
is  not  the  best  food  for  healthy  adults  it  is  difficult  to  conceive  how 
it  can  be  the  most  suitable  in  any  case  of  disease. 

I  have  no  objection  to  milk  in  a  mixed  diet.  It  is  certainly 
good  food  in  combination  with  other  things.  It  is  well  to  remem- 
ber that  some  of  its  modifications,  like  buttermilk  and  kumiss,  are 
frequently  more  useful,  because  more  easily  digested,  than  plain 
cow's  milk.  The  following  dietary  is  what  I  have  prescribed  in 
private  practise  and  in  the  Burnside  Lying-in  Hospital  for  the  last 
ten  years.  Milk,  buttermilk,  kumiss — as  much  as  the  patients 
care  to  drink,  but  no  more ;  plain  water  in  abundance ;  tea  once  a 
day  if  desired ;  cocoa,  lemonade,  mineral  waters,  etc. ;  bread  (not 
too  fresh)  and  butter,  dry  toast  or  cold  toast  and  butter;  rice, 
tapioca,  arrowroot,  etc. ;  fish  without  rich  gravy ;  limited  amount 
of  white  meat  and  raw  oysters ;  limited  amount  of  salt ;  vegetables 
of  all  sorts,  restricting,  however,  the  supply  of  potatoes,  and  en- 
couraging the  use  of  greens,  such  as  lettuce,  spinach,  watercress, 
etc. ;  ripe  fruits,  such  as  oranges,  bananas,  and  grapes — other  fruits 
cooked,  such  as  apples,  pears,  and  peaches. 

I  advise  the  patients  to  choose  what  they  please  from  this  list, 
and  take  especially  the  things  that  appear  to  agree  best  with  them. 
I  desire  them  to  gratify  as  far  as  possible  the  cravings  of  their  stom- 
achs and  to  eat  too  little  rather  than  too  much.  The  majority  of 
patients  suffering  from  toxaemia  in  the  Lying-in  Hospital  take  little 
or  no  milk.  In  my  private  practise  the  majority  of  such  patients 
take  a  certain  amount  of  milk.     A  large  number  also  take  mineral 


290     PEEGNANCY  AND  THE  PUEEPEEIUM 

waters,  especially  Hunyadi  Janos  or  a  mixture  of  Friedrichshall 
and  Carlsbad.  Milk  diluted  with  such  waters  as  the  so-called  soda, 
or  Apollinaris,  or  Sprudel,  or  Vichy,  is  well  liked  by  some.  In  con- 
nection with  the  above  list  of  foods  I  ask  the  patients  not  to  take 
both  milk  and  fish  or  meat  at  the  same  meal.  During  the  last  two 
or  three  years  I  have  in  certain  cases  added  eggs  and  some  of  the 
heavier  meats,  such  as  beef,  mutton,  and  bacon,  to  the  list. 

Among  the  articles  which  should  be  avoided  are  hot  bread  and 
cakes,  pastry,  highly  seasoned  dishes  of  all  kinds,  spices,  cheese, 
nuts,  rich  gravies,  and  dried  foods. 

Medicinal  Treatment. — The  following  is  the  routine  treatment 
carried  out  in  the  Burnside.  As  soon  as  symptoms  of  toxaemia 
arise  the  patient  is  required  to  take  calomel,  2  to  5  grains  in  one 
or  in  divided  doses — say  J  to  1  grain  doses  every  half  hour  for  four 
or  five  doses,  to  be  followed  by  Epsom  salts,  i  to  1  ounce  in 
one-half  hour,  and  thereafter  2  to  4  drams  every  hour  until  a 
free  evacuation  takes  place.  An  enema  is  also  administered,  im- 
mediately after  giving  the  calomel  in  urgent  cases — i.  e.,  when 
the  symptoms  are  severe,  especially  when  there  is  a  large  amount 
of  albumin  in  the  urine  and  a  small  quantity  of  urea  excreted.  In 
less  urgent  cases  a  few  small  doses  of  calomel  (say  i  of  a  grain 
every  half-hour  for  six  doses)  are  administered,  to  be  followed  by 
the  salts.  After  the  bowels  are  freely  opened  smaller  doses  of 
salts  are  given,  sufficient  to  produce  not  less  than  four  watery 
evacuations  in  each  and  every  twenty-four  hours.  For  the  first 
few  days  I  do  not  object  to  twelve  motions  in  twenty-four  hours. 
When  bad  symptoms,  including  albuminuria,  disappear  or  become 
less  severe,  we  stop  the  administration  of  salts  for  a  time,  but  we 
endeavor  to  prevent  anything  approaching  constipation,  and  de- 
sire not  less  than  two  evacuations  of  the  bowels  every  day  until 
after  labor.  I  carry  out  the  same  rules  in  private  practise,  but 
I  do  not  as  a  rule  tell  my  patients  that  I  am  giving  simply  that 
common,  old-fashioned  stuff — Epsom  salts.  I  frequently  give  the 
following  prescription  after  a  short  course  of  free  purgation : 

IJ  Magnesii  sulphatis |  ij ; 

Acidi  tartarici 3  iij ; 

Tincturae  cardamomi  compositse 3  ij ; 

Aquae  ad |  iv. 

A  dessertspoonful  in  hot  water  three  times  a  day. 


GENERAL    TOXiEMIA    OF    PREGNANCY  291 

I  give  the  tartaric  acid  because  it  disguises  the  taste  of  the  salts 
to  such  an  extent  as  to  make  it  quite  or  almost  palatable  for  the 
majority  of  patients.  In  hospital  practise  I  prefer  to  give  the  con- 
centrated solution  alone.  While  I  desire  such  patients  to  drink  as 
much  water  as  possible  at  all  times,  I  consider  it  especially  impor- 
tant that  they  do  so  during  the  free  purgation. 

What  does  magnesium  sulphate  do?  It  removes  noxious  ele- 
ments which  would  otherwise  be.  absorbed  from  the  intestinal 
canal.  It  removes  from  the  blood  a  large  quantity  of  serum  and 
with  that  serum  a  certain  proportion  of  the  "circulating  toxins  " 
without  at  the  same  time  abstracting  the  blood  corpuscles.  It  aids 
the  liver  and  kidneys,  which  without  such  assistance  soon  become 
seriously  diseased  from  the  effects  of  poisoning  and  overwork.  It 
does  away  to  some  extent  at  least  with  the  necessity  of  bleeding  or 
administering  veratrum  viride  if  convulsions  occur. 

Some  object  to  the  long-continued  use  of  cathartics.  A  prom- 
inent American  obstetrician  once  said  in  my  presence,  "A  woman 
can  not  be  purged  for  two  or  three  months. ' '  In  reply  I  have  only 
to  say  a  woman  can  be  purged  for  two  or  three  months  in  the  way 
I  have  indicated.  I  have  seen  it  done  in  many  instances.  Others 
object  because,  as  they  say,  such  treatment  tends  to  produce 
anaemia.  In  reply  to  that  I  wish  to  express  a  very  decided  opinion 
that  it  does  not  tend  to  produce  anaemia.  On  the  contrary,  it  in 
many  cases  somewhat  rapidly  improves  the  condition  of  the  blood 
by  removing  from  the  body  the  poison  which  is,  to  a  large  extent, 
producing  the  anaemia.  Some  years  ago  I  was  rather  timid  about 
pushing  such  treatment  vigorously  in  patients  that  were  weak  and 
anaemic,  but  my  scruples  in  that  respect  have  ceased  to  exist,  be- 
cause I  have  never  seen  it  produce  an  evil  effect.  Of  course,  one 
should  use  ordinary  good  judgment,  watch  carefully  the  results, 
and  act  accordingly. 

It  must  be  acknowledged  that  Charpentier,  one  of  the  strongest 
advocates  of  an  exclusively  milk  diet,  had  remarkably  good  results 
in  his  treatment  of  albuminuria  of  pregnancy.  So  had  Tarnier 
and  others.  But  many  had  not.  Pajot  thought  it  perfectly  use- 
less. Such  direct  contradictions,  which  are  not  rare  in  connection 
with  many  phases  of  this  very  important  subject,  are  perplexing. 
I  think,  however,  that  Charpentier's  success  was  not  due,  as  he 
thought,  to  his  dietary,  but  to  the  fact  that  apart  from  that  he 
carried  out  exactly  the  principles  of  treatment  which  I  have 


292     PEEGNAKCY  AND  THE  PUEEPERIUM 

described.  He  made  "use  of  purgatives  in  a  repeated  and  con- 
stant manner,"  and  tried  "to  obtain,  by  means  of  purgatives,  a 
serous  intestinal  discharge  which  withdraws  from  the  woman  a 
large  quantity  of  serum,  etc."  He  preferred  the  "saline  purga- 
tives." "In  a  word,  we  try  to  produce  a  revulsive  effect  on  the 
intestines."  He  got  good  results  from  free  and  continuous  purga- 
tion with  a  certain  diet.  I  have  had  and  seen  at  least  equally  good 
results  with  free  purgation  and  a  diet  that  he  strongly  condemned. 
I  think  it  fair  to  conclude  that  the  purgation  was  the  important 
element  in  the  success  in  both  instances. 

The  Kidneys  and  Diuresis. — In  a  certain  proportion  of  cases 
the  excretion  of  urine  is  normal  or  excessive  in  quantity ;  in  either 
case,  of  course,  diuretics  would  not  be  indicated.  In  other  cases 
the  quantity  excreted  is  much  reduced,  rarely  total  suppression 
occurs.  When  the  quantity  is  scanty  many  are  tempted  to  give 
diuretics.  Administration  of  the  ordinary  diuretic  medicines 
under  such  circumstances  is  generally,  if  not  always,  harmful. 
Ihere  is  just  one  diuretic  that  I  should  recommend  in  these  cases, 
and  that  is  plain  water.  Dickinson  taught  us  many  years  ago  that 
in  a  large  proportion  of  cases  of  kidney  disease  plain  water  is  the 
best  remedy.  (Some  use  distilled  water.)  Dickinson,  in  giving 
such  recommendations,  was  referring  especially  to  the  effects  of 
congestion  or,  more  properly,  inflammation.  We  may  accept  Ley- 
den's  theory  as  to  the  toxsemic  kidney  and  consider  that  in  such 
the  condition  is  one  of  anaemia  rather  than  congestion,  but  we 
must  remember  that  the  toxines,  or  their  effects,  are  found  in  the 
kidney  substance  and  the  tubules,  and  our  aim  should  be  to  flush 
out  these  organs  with  the  simplest  dilutent  diuretic  at  our  disposal, 
that  is,  water.  I  had  supposed  that  there  was  a  general  consensus 
of  opinion  as  to  the  value  of  water  for  all  sorts  of  lame  or  diseased 
kidneys,  excepting  when  some  such  condition  or  disease  as  glyco- 
suria or  diabetes  is  present.  I  find,  however,  that  a  few  obstetri- 
cians, including  Byers,  recommend  the  withholding  of  liquids  in 
toxaemia  and  especially  in  eclampsia.  I  hold  a  very  decided  opin- 
ion that  the  ingestion  of  liquids  (especially  plain  water)  is  beneficial 
in  both  these  conditions.  It  may  be  that  nitroglycerine  may 
sometimes  act  as  a  safe  diuretic  by  overcoming  the  spasm  of  the 
renal  arteries  which  causes  that  anaemia  described  by  Leyden. 

Skin  and  Diaphoresis.^ — Many  who  believe  in  the  elimination 
treatment  of  toxaemia  and  eclampsia  attach  a  great  deal  of  impor- 


GENERAL    TOX.^MIA    OF    PKEGNANCY  293 

.  tancc  to  the  proper  action  of  the  skin.  I  am  quite  in  sympathy 
with  such  ideas,  but  I  object  to  what  may  be  called  the  aggressive 
method  sometimes  employed.  I  have  not  found  much  benefit 
from  any  ingenious  machines  or  devices  designed  to  cause  profuse 
perspiration ;  I  have,  in  certain  cases,  found  great  prostration  fol- 
low some  of  these  sweating  procedures.  I  dislike,  therefore,  to 
see  the  patient  suffering  from  toxsemia  of  pregnancy  either  cooked, 
baked,  or  parboiled.  I  think,  at  the  same  time,  that  every  preg- 
nant woman,  whether  toxemic  or  not,  should  have  a  daily  warm 
bath.  In  speaking  of  the  treatment  of  eclampsia  I  shall  refer  to 
some  of  the  simpler  devices  which  may  be  of  some  service.  I  shall 
simply  add  now  that  beyond  systematic  bathing  nothing  is  required 
except  sufficient  warm  clothing  with  woolen  fabric  next  the  skin. 
Of  course,  I  accept  the  dictum  of  our  therapeutists  that  the  kidneys 
and  skin  have  functions  which  are  complementary  to  each  other ; 
as  a  consequence,  when  one  is  doing  a  diminished  amount  of  work 
the  other  has  to  do  a  great  deal.  It  seems  right,  therefore,  when 
the  kidneys  become  lame,  to  make  the  skin  do  more  work.  But 
very  little  tissue  waste  is,  under  any  circumstances,  eliminated  by 
the  skin.  As  clearly  pointed  out  by  Sir  Lauder  Brunton,  the  skin 
acts  chiefly  by  eliminating  water  and  by  regulating  temperature 
through  the  evaporation  of  this  water.  Sometimes  a  certain 
amount  of  urea  may  be  found  in  the  sweat,  but,  generally  speaking, 
the  amount  of  solids  eliminated  by  the  skin  is  exceedingly  small. 

Administration  of  Thyroid  Extract. — It  is  supposed  by  some, 
who  think  that  the  most  important  point  in  the  treatment  is  to 
secure  elimination  by  the  kidneys,  that  there  is  an  intimate  rela- 
tionship existing  between  thyroid  function  and  renal  sufficiency. 
According  to  their  views,  inadequate  thyroid  action  causes  dimin- 
ished secretion  of  urine  with  high  pulse  tension  and  oedema  of  a 
more  solid  character  than  that  of  ordinary  dropsy,  more  of  the 
myxoedematous  (Nicholson)  nature.  In  such  cases,  it  is  said,  a 
patient  will  derive  benefit  from  taking  thyroid  extract,  a  5  grain 
(.32  gm.)  tablet  twice  or  three  times  a  day. 

As  I  believe  the  best  means  of  eliminating  the  toxines  is  through 
the  intestinal  canal,  the  thyroid  treatment  does  not  appear  to  me 
to  be  founded  on  correct  principles,  even  though  it  were  true  that 
the  thyroid  gland  and  kidneys  are  to  some  extent  complementary 
in  their  functions.  The  results  from  animal  organotherapy  have 
come  very  far  short  of  fulfilling  expectations.     However,  the  thy- 


294     PKEGNANCY  AND  THE  PUEEPEKIUM 

roid  preparations  appear  to  have  undoubted  value,  especially  in 
myxcedema  and  goitre,  and  I  sometimes  give  the  extract  when  a 
patient  has  the  hard  myxoedematous  swelling  and  scanty  urine, 
with  or  without  the  high  tension  pulse.  One  should  be  cautious  in 
the  use  of  this  remedy  because  it  may  reduce  the  patient's  strength 
out  of  all  proportion  to  the  benefit  derived. 

I  saw  with  C.  H.  Britton  recently  a  patient  who  had  serious 
toxaemia  of  pregnancy.  There  was  oedema  of  legs,  vulva,  and 
lower  portion  of  abdominal  walls.  The  swelling  of  legs  and  thighs 
appeared  to  be  myxoedematous  in  character.  Treatment:  Free 
catharsis  and  thyroid  extract  gr.  iii  (.17  gm.)  three  times  a  day. 
No  improvement  in  symptoms.  Labor  one  week  after  I  saw  her ; 
liAdng  child ;  good  recovery. 

Induction  of  abortion  or  premature  labor  is  considered  in  an- 
other chapter. 

ECLAMPSIA 

The  word  puerperal,  as  applied  to  eclampsia,  is  of  course  a  mis- 
nomer. Eclampsia,  as  we  now  understand  it,  is  the  term  applied 
to  suddenly  occurring  tonic  and  clonic  convulsions  of  the  whole 
body  of  the  pregnant,  parturient,  or  lying-in  woman,  such  convul- 
sions having  associated  with  them  complete  loss  of  consciousness. 
In  accordance  with  this  definition  we  exclude  the  convulsions  of 
epilepsy  and  hysteria  and  also  certain  cerebral  lesions  which  may 
occur  as  accidental  complications. 

Eclampsia  is  due  to  toxsemia  and  therefore  its  causes  are  those 
of  toxsemia.  The  important  cause,  as  before  stated,  is  the  accumu- 
lation of  toxines  within  the  body,  the  liver,  intestines  and  kidneys 
being  chiefly  at  fault.  In  addition  certain  obscure  changes  take 
place  in  the  nervous  system.  We  do  not  know  the  character  of 
these  changes,  but  we  surmise  from  clinical  observation  that  there 
is  extreme  irritability  of  the  nerve  centers,  causing  them  to  become 
explosive  at  certain  critical  periods. 

Frequency. — Eclampsia  is  said  to  occur  once  in  500  labors. 
There  seems,  however,  to  be  quite  a  difference  in  the  statistics  com- 
ing from  different  countries.  The  rates  given  in  various  parts  of 
the  continent  vary  from  about  1  in  300  to  1  in  650.  The  frequency 
in  Great  Britain  is  about  1  in  360 ;  the  frequency  on  this  continent 
is,  I  think,  about  1  in  350. 

The  premonitory  symptoms  are:  Salivation,  disorders  of  di- 


ECLAMPSIA  295 

gestion,  general  malaise,  anaemia,  nervous  disturbances  with  head- 
ache, disorders  of  vision,  etc.,  deficient  excretion  of  urine  or  some 
of  its  constituents  (as,  for  instance,  urea),  albuminuria,  high  ar- 
terial tension,  oedema,  especially  of  lower  extremities. 

These  are  the  actual  symptoms  of  general  toxaemia,  and  are 
repeated  here  because  of  their  importance.  The  following  are  the 
actual  symptoms  of  a  convulsion.  The  first  thing  noticed  is  gen- 
erally a  twitching  of  the  eyelids,  the  face  being  at  the  same  time 
pale ;  spasms  of  the  muscles  of  respiration  soon  occur,  at  the  same 
time  the  head  is  generally  drawn  to  one  side,  the  eyes  are  turned 
inward,  and  the  face  gets  dark  in  color ;  the  thumbs  are  generally 
turned  in.  This  is  the  commencement  of  the  tonic  stage  during 
which  the  patient  lies  with  all  her  muscles  rigidly  contracted. 

Next  come  the  clonic  spasms.  Twitching  begins  at  the  face 
and  eyes  and  extends  to  more  violent  jerking  movements  of  the 
head  and  neck  and  of  the  limbs.  The  face  becomes  still  more  cyan- 
osed  and  greatly  disfigured ;  in  fact  the  disfigurement  amounts  to 
a  horrible  distortion  which  transforms  a  face,  no  matter  how  beauti- 
ful it  may  be,  into  something  indescribably  repulsive,  requiring 
to  be  seen  before  it  can  be  fully  appreciated.  The  tongue  is  pro- 
truded and  often  bitten.  Foam  stained  with  blood  pours  out  from 
the  mouth,  while  the  breath  escapes  with  a  hissing  sound. 

In  giving  this  description  I  have  followed  Galabin  closely,  but 
the  description  will  not  fit  all  cases.  In  some  cases  the  fits  begin 
with  twitching  of  the  face  and  eyeballs,  while  the  tonic  and  clonic 
spasms  of  the  muscles  of  the  Hmbs  seem  to  alternate.  Sometimes 
no  clear  distinction  can  be  made  between  the  tonic  and  clonic 
stages,  especially  when  the  fits  succeed  each  other  rapidly.  Some- 
times in  tonic  spasms  the  back  may  be  arched  as  in  opisthotonos. 
The  patient  is  completely  unconscious  during  the  convulsions. 
Urine  and  faeces  may  be  passed.  A  single  fit  lasts,  on  an  average, 
from  one  to  one  and  a  half  minutes.  It  is  generally  followed  by 
deep  sleep  with  stertorous  breathing.  When  the  fits  are  frequent 
the  patient  does  not  recover  consciousness  during  the  intervals. 
In  mild  cases — that  is,  when  there  is  only  one  fit,  or  a  few  fits  at 
long  intervals — consciousness  may  return  after  the  single  fit  or 
during  the  intervals,  but  the  patient  has  no  remembrance  of 
what  has  occurred  and  is  always  more  or  less  confused. 

I  have  a  patient  who  some  years  ago  had  four  convulsions  with 
complete  loss  of  consciousness  during  their  continuance,  who  to- 


296     PEEGNANCY  AND  THE  PUEEPEKIUM 

day  has  not  the  sHghtest  idea  that  she  ever  had  a  fit.  In  some  of 
these  cases,  even  while  the  patient  is  unconscious,  reflex  sensibihty 
is  shown  when  the  labor  pains  occur  or  when  she  is  touched,  as,  for 
instance,  during  a  vaginal  examination.  The  sensibility  of  the 
pupils  to  light  is  generally  diminished.  They  may  be  dilated  or 
contracted,  but  generally  are  contracted  shortly  before  and  during 
the  paroxysm.  Braxton  Hicks  thought  that  the  uterus,  at  least 
sometimes,  took  part  in  the  paroxysm  and  that  in  many  cases  the 
uterus  may  be  felt  to  harden  immediately  before  the  convulsions 
come  on.  In  other  cases  the  paroxysm  may  induce  a  tetanic 
contraction  of  the  uterus  lasting  several  minutes  longer  than  an 
ordinary  labor  pain.  Spiegelberg,  however,  does  not  agree  with 
these  conclusions. 

As  an  effect  of  the  repeated  convulsions  the  pulse  becomes  rapid 
and  sometimes  small.  The  rate  is  frequently  from  120  to  140. 
Galabin  tells  us  that  from  sphygmographic  tracings,  taken  during 
the  eclamptic  state,  he  has  found  that  the  pulse  is  not  a  dicrotic 
pulse  with  low  tension,  like  the  ordinary  rapid  pulse  of  fever,  but 
one  of  abnormally  high  tension  like  that  observed  in  Bright 's 
disease.  In  certain  cases,  when  the  fits  recur  at  short  intervals,  the 
temperature  may  rise  to  a  very  unusual  height,  some  say  as  high  as 
108°  or  109°. 

Diagnosis. — The  diagnosis  of  eclampsia  is  generally  easy.  The 
diseases  from  which  it  must  be  especially  distinguished  are  epilepsy 
and  cerebral  disease,  as  these  are  the  only  two  diseases,  outside  of 
eclampsia,  in  which  fits  occur  with  total  loss  of  consciousness. 
As  to  the  first  we  can  generally  learn  from  the  history  that  epilepsy 
has  existed  previously.  In  cerebral  disease,  such  as  haemorrhage, 
there  are  generally  signs  of  paralysis ;  and  in  meningitis  fever  has 
existed  previously.  We  may  also  require  to  distinguish  it  from 
hysteria,  coma,  and  drunkenness.  In  hysteria  there  is  never  com- 
plete loss  of  consciousness  nor  the  extreme  respiratory  spasm 
which  exists  in  eclampsia.  In  cases  of  drunken  dehrium  we  may 
diagnose  the  condition  from  the  history  of  the  case  and  from  the 
alcoholic  odor  of  the  breath. 

Eclampsia  occurs  much  more  frequently  in  primiparse  than  in 
multiparse,  the  proportion  between  the  two  being  as  80  per  cent, 
to  20  per  cent.  According  to  Vinay,  its  frequency  in  primiparse 
is  due  to  the  slowness  of  labor,  the  increase  of  intra-abdominal 
pressure  owing  to  the  inextensibihty  of  the  parts,  the  too  early 


ECLAMPSIA  297 

engagement  of  the  head  which  compresses  the  ureters,  the  greater 
frequency  of  albuminuria,  and  to  the  far  greater  reflex  excita- 
biUty.  Elderly  priniipara)  arc  especially  liable.  Multipane  are 
most  frequently  affected,  in  the  second  or  third  pregnancy.  1  think 
it  is  not  generally  understood  that  a  recurrence  of  eclampsia  in  a 
second  pregnancy  is  I'are,  probably  not  occurring  in  more  than 
2  per  cent,  of  the  cases.  It  would  seem  from  this  that  one  attack 
of  eclampsia  confers  immunity  to  a  greater  or  less  extent  in  sub- 
sequent pregnancy. 

Prognosis. — The  mortality  both  to  the  mothers  and  babes  from 
eclampsia  is  high,  probably  about  25  per  cent.,  being  especially 
high  in  patients  attacked  before  labor.  The  prognosis  as  far  as  the 
mother  is  concerned  is  perhaps  best  indicated  by  the  number  of 
the  fits.  It  is  hard  to  give  any  definite  number,  especially  as  death 
may  result  from  one  convulsion,  particularly  if  cerebral  haemor- 
rhage or  pulmonary  fat-embolism  occurs.  However,  I  am  in- 
clined to  agree  with  Diihrssen,  who  thinks  that  when  there  are 
more  than  ten  fits  the  prognosis  is  bad.  Rosenstein,  however, 
reports  one  case  of  recovery  after  eighty-one  fits. 

Morbid  Anatomy. — Post-mortem  examinations  have  not  cleared 
up  doubtful  points  in  pathology  as  satisfactorily  as  one  might  have 
expected.  In  giving  a  few  notes  as  to  morbid  anatomy  I  shall 
follow  Jellett.  He  tells  us  that  in  post-mortem  examinations  made 
on  women  who  have  died  of  eclampsia  we  find  a  series  of  more  or 
less  constant  morbid  conditions,  but  nothing  which  can  be  regarded 
in  the  light  of  a  primary  lesion. 

The  liver  is  more  yellow  in  color  than  usual,  due  to  commen- 
cing fatty  degeneration  or  varying  lesions  of  the  epithelium  (Pil- 
liet).  Small  haemorrhages  are  met  with  both  beneath  the  capsule 
and  in  the  liver  substance,  and  also  areas  of  necrosis  round  the 
portal  spaces,  from  which  emboli — of  fat  (Virchow) — of  Uver  cells 
(Jiirgens)  may  be  carried  to  other  organs. 

The  kidneys  are  diseased  in  from  90  to  95  per  cent,  of  cases. 
The  commonest  condition  found  is  that  known  as  the  pregnancy 
kidney  (toxaemic).  Chronic  nephritis  is  more  rarely  present. 
Minute  areas  of  necrosis  resembling  those  met  with  in  the  liver  are 
found  distributed  around  some  of  the  convoluted  tubules.  In  a 
very  small  proportion  of  cases  the  renal  changes  may  be  attributed 
to  the  effects  of  obstructive  suppression  of  urine  due  to  pressure 
upon  the  ureters.     The  spleen  is  enlarged,  congested,  and  soft. 


298     PEEGNANCY  AND  THE  PUEEPERIUM 

Areas  of  necrosis,  as  in  the  liver,  are  met  with,  and  small  haemor- 
rhages beneath  the  capsule  and  in  the  spleen  substance  (Bouffe  de 
Saint-Blaise).  The  pancreas  also  presents  areas  of  necrosis  and 
may  be  very  anaemic. 

The  brain  is  sometimes  hyperaemic,  sometimes  anaemic,  and 
somewhat  oedematous,  with  consequent  softening  of  the  convolu- 
tions and  showing  minute  haemorrhages  in  various  parts.  The 
lungs  are  usually  oedematous,  especially  at  their  bases ;  subpleural 
ecchymoses  are  seen,  and  emboh  are  found  which  may  come  from 
the  liver.  Changes  have  been  met  with  in  the  liver  and  kidneys 
of  the  foetus  resembling  those  which  occur  in  the  mother.  The 
placenta  is  frequently  the  seat  of  white  infarction,  and  it  is  thought 
that  from  these  areas  placental  giant-cells  may  pass  into  the  blood. 

Causes  of  Death  in  the  Mother  and  Child. — According  to  Chfton 
Edgar,  the  causes  of  death  in  the  mother  are:  exhaustion;  apo- 
plexy, from  forcible  rupture  of  the  cerebral  vessels;  asphyxia, 
due  to  spasm  of  the  muscles  of  the  glottis  and  of  respiration ; 
pulmonary  and  cerebral  oedema,  the  result  of  serous  effusions  from 
distended  capillaries;  cerebral  congestion,  of  which  coma  is  a 
symptom,  and  paralysis  of  the  heart.  The  last  when  it  occurs 
in  the  general  spasm  causes  instant  death.  The  causes  of  the 
death  of  the  child  are :  the  mother's  convulsions  and  the  pressure 
exerted  by  them;  asphyxia,  from  compression  or  oedema  of  the 
placenta,  or  the  excessive  carbon  dioxide  in  the  blood,  and  pos- 
sibly direct  poisoning  by  the  toxic  material  in  the  maternal  circu- 
lation. 

TREATMENT 

The  opinions  of  leading  obstetricians  in  various  parts  of  the 
world  respecting  the  treatment  of  toxaemia  and  eclampsia  are  so 
many  and  so  diverse  that  it  is  difficult  or  impossible  to  do  full 
justice  to  the  subject  in  the  space  at  my  disposal.  It  is  well  to 
take  a  broad  view  of  the  subject  and  avoid  narrow  ideas  as  to  the 
superexcellence  of  any  one  medicine  or  any  one  line  of  treatment. 
In  one  case  we  may  have  a  plethoric  patient  with  a  full,  bounding 
pulse ;  in  another  we  may  have  an  anaemic  patient  with  a  very  weak 
and  flabby  pulse ;  and  we  may  have  various  grades  between  these 
two  extremes.  One  can  very  easily  understand  that  the  suitable 
treatment  for  the  able-bodied,  plethoric  patient  would  be  disas- 
trous for  the  weak,  anaemic  patient. 

In  speaking  of  the  different  medicines  I  shall  try  in  the  first 


ECLAMPSIA  299 

place  to  recommend  those  medicines  which  are  suited  for  all  cases, 
and  shall  then  speak  of  other  medicines  which  are  suitable  under 
special  circumstances.  In  considering  the  different  lines  of  treat- 
ment pursued  by  different  schools  one  learns  that  each  method 
generally  combines  two  or  more  remedies.  The  following  com- 
binations are  among  the  most  common:  Morphine  and  chloral, 
chloroform  and  chloral,  morphine  and  veratrum  viride,  morphine 
and  bleeding,  bleeding  and  transfusion  of  salt  solution,  etc.  There 
are  also  such  combinations  as  morphine,  chloroform  and  chloral 
with  subcutaneous  injection  of  normal  salt  solution 

The  so-called  morphine  treatment  of  eclampsia  will  be  first 
described.  This  treatment  has  been  commonly  used  in  parts  of 
Germany,  France,  the  United  States  and  Canada,  during  the  last 
fifteen  to  twenty-five  years.  It  was  looked  on  with  much  disfavor 
in  Great  Britain  for  many  years,  but  its  comparatively  recent 
adoption  by  the  Dublin  school  in  the  Rotunda  Hospital  has  made 
it  popular  in  many  parts  of  the  British  Islands.  The  modified 
morphine  treatment,  which  has  been  carried  out  for  twenty  years 
in  the  Toronto  Burnside,  has  generally  proved  satisfactory.  It 
will  be  seen  that  we  do  not  depend  on  morphine  alone.  Our  rules 
are  as  follows : 

Morphine. — When  a  fit  occurs  give  immediately  ^  grain  of 
morphine  by  hypodermic  injection ;  if  fits  recur  give  ^  of  a  grain 
every  half  hour  for  two  doses — that  is  to  say,  give  1  grain  of 
morphine  in  one  hour.  If  the  convulsions  still  continue  after 
the  hour,  give  ^  grain  every  two  to  four  hours,  but  do  not  give 
more  than  2^  to  3  grains  in  twenty-four  hours. 

Chloroform. — Administer  a  little  chloroform  during  the  con- 
vulsion, always  withholding  it  during  the  interval  between  the  fits. 
Aim  at  giving  as  little  chloroform  as  possible. 

Chloral. — Administer  chloral  (in  milk,  never  as  a  watery  solu- 
tion, because  the  latter  is  apt  to  produce  rectal  tenesmus)  per 
rectum  after  ceasing  to  use  chloroform,  30  to  60  grains  every  four  to 
eight  hours. 

Saline  Injections. — Use  injection  of  normal  salt  solution  high 
up  in  rectum,  or  subcutaneously  under  the  breast  or  in  the  loose 
tissue  of  the  abdominal  wall,  one  teaspoonful  each  of  common 
salt  and  acetate  of  soda  to  the  pint.  Jardine  thinks  that  the  latter 
mixture  has  greater  diuretic  effect.  Inject  ^  to  2  pints  every  four 
or  six  hours  as  long  as  thought  necessary. 


300     PEEGNANCY  AND  THE  PUEEPERIUM 

Saline  Irrigation  of  the  Intestine. — Egbert  Grandin  advises  hot 
saline  irrigation  of  the  intestine,  using  for  the  purpose  8  or  10 
gallons  of  the  solution.     His  method  is  described  on  page  303. 

Croton  Oil  or  Elaterium. — If  the  patient  is  plethoric,  or  even 
fairly  strong,  administer  one  to  two  drops  of  croton  oil,  mixed  with 
a  little  butter,  and  placed  as  far  back  upon  the  tongue  as  possible, 
or  |-  of  a  grain  of  elaterium. 

Calomel. — If  the  patient  can  swallow  give  by  the  mouth  five 
grains  of  calomel,  particularly  if  this  has  not  been  administered 
before  the  onset  of  the  fits. 

Rectal  Enemata. — Administer  a  cathartic  enema  soon  after 
giving  the  croton  oil  or  calomel.  The  saline  enema,  composed  as 
follows,  is  probably  the  best :  Add  to  a  pint  of  soap-suds  1  des- 
sertspoonful of  turpentine,  2  ounces  of  glycerine,  and  1  ounce  of 
Epsom  salts. 

Epsom  Salts. — Try  to  secure  free  and  almost  continuous  cathar- 
sis by  the  administration  of  Epsom  salts  as  soon  as  the  patient  can 
be  made  to  swallow.  The  best  way  to  administer  this  is  to  give  a 
saturated  solution  in  small  doses,  2  to  4  drams. 

Veratnim  Viride. — In  a  certain  proportion  of  cases,  especially, 
when  there  is  a  full,  strong  pulse,  give  tincture  of  veratrum  viride 
by  hypodermic  injection,  10  minims  at  once  and  5  minims  every 
half  hour  thereafter,  until  the  pulse  comes  down  to  60  or  there- 
abouts. 

Venesection. — Instead  of  using  veratrum  viride  one  may  re- 
move from  the  arm  from  12  to  18  ounces  of  blood,  but  should 
never  combine  the  administration  of  veratrum  viride  and  vene- 
section in  the  same  patient. 

Diet. — Give  the  patient  very  little  solid  food  (considering  milk 
as  a  solid  food) ,  but  plenty  of  water ;  milk  well  diluted  with  ordi- 
nary water,  or  with  tea,  or  with  aerated  waters,  will  answer  very 
well  for  two  or  three  days.  Beyond  this  carry  out  the  rules  as 
to  diet  for  toxaemia  of  pregnancy.  (See  page  289.)  When  the 
patient  is  in  labor  accelerate  delivery  as  far  as  possible. 

Before  going  any  further  into  details  as  to  treatment  I  may 
perhaps  make  certain  comparisons.  As  far  as  Great  Britain  is 
concerned  the  two  favorite  methods  of  treatment  at  present  are 
probably  what  may  be  briefly  termed  the  morphine,  on  the  one 
hand,  and  the  chloroform  and  chloral  on  the  other.  I  think  that 
chloroform  given  in  anything  like  a  large  quantity  is  decidedly 


ECLAMPSIA  301 

bad,  because  it  is  very  depressing,  while  at  the  same  time  its 
action  is  temporary.  Chloral  is  also  depressing,  and  therefore  the 
administration  of  these  two  medicines  at  one  time  is  especially  dan- 
gerous in  the  weak  and  anaemic.  On  the  other  hand,  morphine  is 
free  from  these  objections.  Lyle,  one  of  the  representatives  of  the 
Dublin  School,  tells  us  that  it  has  the  following  advantages:  1.  It 
controls  the  convulsion  by  allaying  the  irritability  of  the  cerebro- 
spinal system,  2.  It  prevents  excess  of  waste  products  being 
thrown  into  the  blood.  3.  It  does  not  weaken  the  patient.  4.  It 
does  not  injure  the  child.  5.  It  has  no  effect  on  the  kidneys. 
6.  When  the  patient  is  under  its  influence  labor  often  commences 
and  quickly  terminates  without  causing  more  convulsions. 

While  Lyle  was  in  the  Rotunda  he  treated  18  cases  by  the 
administration  of  morphine,  with  one  death.  In  this  case  the 
morphine  appeared  to  have  no  effect,  the  convulsions  continued 
frequent  and  severe  and  the  temperature  rose  rapidly  to  106.6°  F. 

Morphine  and  Chloral  Combination. — The  joint  administration 
of  these  two  remedies  is  generally  effective  and  has  not  the  de- 
pressing tendency  of  a  chloroform  and  chloral  combination.  The 
morphine  is  given  first  because  its  effect  is  both  more  rapid  and 
pronounced.  The  chloral  is  given  second  because  we  think  it  is 
the  best  remedy  at  our  disposal  to  prevent  the  recurrence  of  the 
fits  after  they  have  been  brought  under  subjection  by  the  morphine. 

Morphine  and  Veratrum  Combination. — The  combined  admin- 
istration of  morphine  and  veratrum  viride  is  probably  worthy  of 
more  consideration  than  it  has  generally  received.  Although  I 
have  administered  veratrum  viride  a  few  times  in  hospital  and  also 
in  private  practise,  I  have  generally  found  negative  results.  It  may 
be  because  I  have  not  given  it  in  sufficiently  large  doses,  and,  in 
addition,  it  may  be  that  the  preparations  I  have  used  were  not 
always  reliable. 

Veratrum  Viride.— It  is  somewhat  remarkable  that  such  con- 
flicting opinions  as  to  the  efficacy  of  veratrum  viride  should  be  ex- 
pressed by  competent  obstetricians  in  the  United  States.  Reamy 
says  that  it  arrests  the  convulsions,  produces  diaphoresis  and  diu- 
resis— that  is  to  say,  it  cuts  short  the  attack,  and  then  acts  most 
efficiently  in  the  removal  of  the  cause.  In  comparison  with  blood- 
letting he  says  that  veratrum  viride  is  at  least  equally  effective, 
while  the  after  effects  are  better.  He  contends  that  it  is  not  danger- 
ous when  the  patient  is  kept  in  the  recumbent  posture.    If  alarming 


302     PEEGNANCY  AXD  THE  PUEEPERIUM 

depression  should  intervene,  morphine  or  tincture  of  opium,  hypo- 
dermically,  will  at  once  remove  the  unpleasant  symptoms.  This 
furnishes  oae  of  the  reasons  why  the  administration  of  these  two 
medicines,  morphine  and  veratrum  viride,  is  especially  suitable. 

Clifton  Edgar  says  with  a  pulse  strong  as  well  as  rapid,  vera- 
trum viride  affords  the  most  certain  means  at  our  command  for 
temporarily,  or  even  permanently,  controlling  the  spasms. 

Hirst  says  veratrum  viride  is  most  valuable  in  cases  with  a 
strong,  bounding  pulse,  with  suffused  face,  and  danger  of  cerebral 
apoplexy.  In  an  asthenic  patient  with  feeble  pulse  and  pale  face 
it  should  not  be  employed. 

Davis  says  in  cases  with  full  heavy  pulse  and  increased  pulse 
tension  it  lessens  arterial  tension,  slows  the  pulse,  diminishes  the 
tendency  to  convulsions,  and  promotes  the  dilatation  of  the 
cervix  uteri. 

Morris  says  when  the  pulse  is  feeble  and  rapid,  the  patient 
profoundly  toxic  and  unresponsive  to  the  usual  treatment,  he  has 
never  seen  any  benefit  from  veratrum ;  indeed,  such  cases  require 
stimulation  of  the  circulation,  rather  than  depression. 

Boyd  says  if  used  at  all  it  is  indicated  only  in  the  asthenic 
cases.  He  has  used  it  to  its  physiological  effect,  reducing  the 
pulse  rate  from  130  to  70  with  no  improvement  in  the  patient's 
condition,  but  rather  acting  as  a  powerful  depressant. 

Marx  denies  the  statement  that  under  its  influence  the  pulse 
becomes  soft,  slow  and  compressible,  and  then  convulsions  cease. 
He  has  seen  awful  convulsions  when  the  pulse  was  60  and  alarm- 
ingly feeble.  In  a  fatal  case,  that  of  the  wife  of  a  physician,  a  con- 
vulsion occurred  one-half  hour  after  an  induced  labor.  The  pulse 
was  full  and  bounding  and  178  to  the  minute.  Hypodermics  of 
full  doses  of  veratrum  viride  sent  the  pulse  down  to  50,  when  it  was 
hardly  to  be  felt,  and  yet  the  worst  convulsion  the  patient  ever 
had  occurred  at  this  time,  and  she  succumbed  to  the  malady  in  a 
short  time.  And  yet,  in  another  woman,  full  doses  of  a  rehable 
preparation  were  given  to  control  the  fits  while  the  pulse  was  full 
and  bounding  and  the  face  deeply  cyanotic,  and  neither  the  pulse 
nor  the  very  severe  convulsions  were  controlled. 

Saline  Injections. — The  use  of  saline  injections  (mentioned  on 
page  299)  has  become  very  popular  in  recent  years,  especially  in 
the  treatment  of  eclampsia,  puerperal  septicaemia,  and  anaemia 
from  severe  haemorrhages.    The  effects  are,  in  toxaemia  and  ec- 


ECLAMPSIA  303 

lampsia,  to  dilute  and  delay  the  action  of  the  poison,  to  stimulate 
the  patient  as  in  cases  of  sepsis,  and  to  cause  diuresis  and  more  or 
less  diaplioresis. 

It  is  well,  however,  to  remember  that  dangers  may  result  from 
excessive  use.  As  a  writer  in  Obstetrics  recently  put  it — carried 
along  by  our  enthusiasm  and  imbued  with  a  sense  of  the  innoc- 
uousness  of  water  and  a  pinch  of  salt,  we  may  not  realize,  until  con- 
fronted by  an  unhappy  experience,  that  it  is  quite  easy  to  drown 
a  patient  with  artificial  blood  serum.  Four  pints  in  twenty-four 
hours  should  be  the  maximum  amount  injected. 

Direct  introduction  of  the  salt  solutions  into  the  vessels  is  the 
most  difficult  and  probably  the  most  dangerous  method,  because 
of  the  possibility  of  the  admission  of  air,  and  the  danger  of  sepsis. 
Another  danger  that  is  not  so  generally  recognized  is  overdisten- 
tion  of  the  heart.  The  strain  upon  the  heart  from  the  convul- 
sions is  already  very  great ;  this  strain  may  be  increased  by  over- 
distention  of  the  heart  through  the  direct  venous  injections. 
Subcutaneous  injection  is  more  easy  of  performance  than  intra- 
venous and  much  less  dangerous.  There  is,  however,  always  one 
element  of  danger,  from  sepsis. 

The  third  method,  of  introduction  of  liquids  into  the  alimentary 
canal,  is  altogether  the  safest,  and  for  ordinary  purposes  should  be 
considered  the  best.  We  require  no  complicated  apparatus  and 
we  practically  have  no  danger  to  fear.  If  these  saline  enemata  are 
administered  with  care  high  up  into  the  colon,  they  are  generally 
retained  and  quickly  absorbed.  For  an  ordinary  physician,  espe- 
cially in  country  practise,  direct  venous  injection  is  especially  diffi- 
cult and  serious,  while  the  subcutaneous  injection  is  by  no  means 
easy.  In  all  instances,  however,  the  injection  into  the  bowel  is 
comparatively  simple  and  easy.  But  one  should  be  prepared  at 
any  time  to  give  the  subcutaneous  injection  when  required. 

Hot  Saline  Irrigation  of  the  Intestines. — Copious  irrigation  of 
the  bowel  has  been  mentioned.  Grandin  describes  his  method  as 
follows : 

The  woman  is  placed  in  the  left  lateral  position,  with  buttocks 
elevated  and  head  lowered ;  a  large  rectal  tube  is  inserted  into  the 
bowel  as  far  as  may  be,  usually  up  to  the  sigmoid  flexure ;  the  rec- 
tal tube  is  connected  with  a  gravity  syringe  which  is  hung  at  least 
six  feet  above  the  head  of  the  patient.  If  such  a  syringe  is  not  at 
hand  the  physician  will  find  a  funnel  in  every  household  and  this 
21 


304    PEEGNANCY  AND  THE  PUERPEEIUM 

may  be  connected  with  the  rectal  tube  by  means  of  rubber  tubing. 
The  strength  of  the  solution  of  hot  salt  water  should  be  about  1  per 
cent,  and  the  temperature  of  the  water  in  the  reservoir  about  118°. 
An  attendant  should  hold  the  rectal  tube  at  the  anal  margin  to 
prevent  its  being  expelled  as,  under  the  peristalsis  of  the  bowel, 
the  water  is  driven  out.  From  8  to  10  gallons  of  water  should  be 
allowed  to  flow  into  the  bowel,  a  large  proportion  of  which  of  course 
returns.  This  accomplished,  the  woman  should  be  wrapped  in 
blankets  and  made  comfortable  in  bed;  in  the  mean  time  croton 
oil  may  be  placed  on  the  tongue  and  glonoin  (niti'oglycerine)  may 
be  administered  in  full  doses  hypodermically,  if  the  character  of 
the  pulse  demands  it. 

It  may  be  stated  here  that,  as  a  rule,  in  the  condition  under 
consideration  glonoin  is  called  for,  but  the  dosage  must  be  large — 
that  is  to  say,  fully  -^-^  of  a  grain  or  4  minims  of  the  officinal  Liq. 
trinitrini,  repeated  half-hourly  until  the  physiological  effect  has 
been  secured.  This  drug  offers  us  the  readiest  of  all  means  for 
relaxing  the  spasm  of  the  renal  capillaries. 

Very  soon  after  irrigation  profuse  diaphoresis  sets  in,  followed 
by  abatement  in  the  alarming  symptoms,  and  shortly  thereafter 
the  kidneys  may  begin  to  excrete  again.  The  explanation  of  the 
effect  of  the  hot  saline  bowel  irrigation  is  not  far  to  seek ;  the  nerve 
centers  are  stimulated,  the  kidneys  are  directly  stimulated,  the 
skin  is  called  into  action,  peristalsis  of  the  intestinal  tract  is  evoked  ; 
in  short,  every  indication  is  promptly  met. 

I  have  given  Dr.  Grandin's  description  and  his  explanation  of 
it  almost  in  his  own  words.  In  one  case  I  ordered  the  nurse  to 
carry  out  this  line  of  treatment,  but  she  was  unable  to  do  so  satis- 
factorily. I  have  had  it  in  view  in  three  or  four  other  cases,  but 
the  ordinary  saline  enemata  had  such  good  effect  that  I  did  not 
try  this  copious  irrigation.  I  think,  however,  that  it  ought  to 
prove  very  efficacious  in  certain  instances.  I  have  not  used  glonoin 
during  eclampsia,  but  I  have  sometimes  found  it  very  useful  in 
certain  cases  of  chronic  nephritis  (see  page  278). 

Croton  Oil. — It  is  very  important  in  connection  with  the  treat- 
ment of  eclampsia  to  avoid  a  mere  routine  plan  of  medication. 
Medicine  which  may  be  quite  useful  in  one  case  may  kill  the  patient 
in  another.  Croton  oil  is  one  of  these.  Croton  oil  should  never 
be  administered  to  a  patient  who  is  weak  and  exhausted. 

Some  years  ago  I  saw  a  patient  after  she  had  passed  through 


ECLAMPSIA  305 

several  convulsions.  Two  drops  of  croton  oil  had  been  adminis- 
tered shortly  before  my  arrival.  She  had  a  flickering,  weak  pulse. 
Life  was  trembling  in  the  balance.  The  croton  oil,  however,  was 
(I  thought)  doing  its  work.     She  soon  ceased  to  breathe. 

In  two  other  instances  in  recent  years  I  have  advised  against 
croton  oil,  with  a  firm  conviction  that  its  administration  would 
kill  the  patient.  In  my  own  practise  I  give  croton  oil  to  only  a 
small  proportion  of  patients  suffering  from  eclampsia. 

Pilocarpine. — Notwithstanding  many  warnings,  the  medical 
world  does  not  fully  appreciate  the  grave  dangers  involved  in  the 
administration  of  pilocarpine.     The  following  report  will  illustrate : 

A  patient  in  the  Burnside  was  seized  with  eclampsia.  Had 
four  convulsions  during  labor,  three  after.  Treatment:  chiefly 
morphine,  cathartics,  saline  injections  'per  rectum  and  subcutane- 
ously.  Two  excellent  house  surgeons  were  in  charge  during  the 
night.  Patient  very  low  at  2  a.  m.  One  dose  of  pilocarpine  given 
hypodermically  to  act  on  the  skin  as  a  last  resort.  Soon  there  was 
a  very  copious  secretion  in  the  bronchial  tubes  which  threatened 
to  choke  the  patient,  and  it  was  thought  for  two  hours  that  she 
could  not  recover.  Her  relatives  were  sent  for.  By  putting  the 
patient  on  her  side  and  keeping  her  head  low  and  turning  it  in  such 
a  way  as  to  allow  liquid  to  flow  from  the  mouth,  and  with  the  ad- 
ministration of  strychnine,  she  finally  rallied.  Miss  McKellar,  the 
matron,  was  unfortunately  in  bed  when  the  pilocarpine  was  ad- 
ministered, and  the  doctors  did  not  know  that  I  had  given 
standing  orders  that  no  dose  of  pilocarpine  was  to  be  administered 
to  any  patient  unless  ordered  by  a  member  of  the  visiting  staff. 

About  twenty  years  ago  a  patient  was  attended  by  two  physi- 
cians of  Toronto,  one  of  whom  was  the  late  Dr.  MacFarlane.  A 
dose  of  pilocarpine  was  administered  and  was  soon  followed  by 
this  copious  bronchial  secretion,  which  killed  the  patient  in  a  few 
minutes,  notwithstanding  all  the  efforts  of  the  physicians  to  pre- 
vent such  a  catastrophe. 

Many  similar  results  have  been  reported  by  physicians  in  differ- 
ent parts  of  the  United  States  and  Canada.  The  late  Fordyce 
Barker  gave  due  warning  as  to  these  dangers  something  like 
twenty-five  years  ago,  but  it  took  the  medical  world  a  long  time 
to  learn  the  lesson  which  he  tried  to  convey.  The  rank  and  file  of 
the  physicians  in  Great  Britain  appear  not  to  have  learned  it  yet. 
I  see  many  reports  from  physicians,  published  in  the  Lancet  and 


306     PREGNANCY  AND  THE  PUEEPERIUM 

British  Medical  Journal,  of  cases  where  pilocarpine  appears  to  be 
administered  as  a  matter  of  course. 

Not  long  since  Pollock  Simpson  gave  a  report  of  three  cases  of 
eclampsia  in  the  Lancet.  In  his  notes  as  to  treatment  he  speaks  of 
morphine  as  being  of  great  value  where  paraglobulin  predominates 
in  the  urine.  Chloral,  bromide,  and  chloroform,  he  says,  are  all 
valuable,  but  where  all  the  above  remedies  fail  -i-  of  a  grain  of 
pilocarpine  given  hypodermically  will  produce  profuse  diapho- 
resis in  twenty  minutes. 

The  most  unfortunate  feature  in  connection  with  such  treat- 
ment is  that  the  pilocarpine  is  apt  to  be  administered  as  a  last 
resort  after  other  remedies  fail — that  is,  just  at  that  particular 
time  when  the  pilocarpine  is  most  apt  to  produce  its  deadly  effects 
on  the  patient. 

ACUTE   OR  CHRONIC  NEPHRITIS  WITH   ECLAMPSIA 

Certain  views  have  been  expressed  as  to  the  proper  treatment 
of  ordinary  nephritis  in  pregnancy.  A  few  words  may  now  be 
added  respecting  acute  and  chronic  nephritis  and  their  connection 
with  that  form  of  auto-intoxication  of  pregnancy  which  I  have 
called  eclampsic  toxaemia.  I  have  endeavored,  to  some  extent, 
to  disassociate  the  chronic  nephritis  from  the  toxaemia,  but  it 
should  be  remembered  that  they  may  occur  together.  A  certain 
proportion  of  women  with  nephritis  show  evidences  of  toxaemia 
during  pregnancy. 

The  Induction  of  Abortion  or  Premature  Labor. — The  induction 
of  abortion  or  premature  labor  is  not  advisable  nor  justifiable,  ex- 
cepting as  a  last  resort,  when,  after  all  other  methods  have  failed, 
the  patient's  life  appears  to  be  endangered.  The  following  quota- 
tions from  certain  authors  will  show  to  some  extent  the  differences 
of  opinion  which  exist : 

Charpentier  says  we  must  wait  until  the  labor  begins  spon- 
taneously and  let  it  go  undisturbed  when  it  is  possible.  We  must 
induce  the  labor  only  in  exceptional  cases.  Caesarean  section  and 
"accouchement  force"  are  to  be  absolutely  rejected  as  usual 
methods  for  the  treatment  of  eclampsia.  We  must  have  recourse 
to  these  operations  only  in  cases  of  failure  of  every  medicine  and 
when  the  mother  seems  on  the  point  of  dying.  In  short,  we  must 
keep  it  as  a  last  resource  in  desperate  cases. 


ECLAMPSIA  307 

Mangigalli  tells  us  that  the  prompt  evacuation  of  the  uterus 
constitutes  the  most  important  point  of  the  treatment  of  eclampsia. 
In  eclampsia  during  labor  it  is  a  good  rule  to  finish  the  accouche- 
ment when  the  permitting  conditions  exist,  and  to  anticipate  these 
by  means  of  several  incisions  of  the  cervix  when  the  dilatation  is 
not  sufficient.  When  the  eclampsia  occurs  before  labor,  he  advises 
the  induction  of  labor  by  means  of  the  rupture  of  the  membranes 
and  the  administration  of  morphine  or  chloral  or  veratrum  \dride, 
and  thinks  that  sometimes  forced  dilatation  is  better  than  the 
incisions  of  the  cervix. 

Diihrssen  says  when  eclampsia  has  already  set  in  the  only 
rational  treatment  is  the  immediate  emptying  of  the  uterus  under 
deep  anaesthesia.  With  this,  as  he  has  proved  in  93  per  cent, 
of  the  cases,  the  eclampsia  ceases  at  once  or  very  soon.  The  dan- 
gers of  the  operative  interference  are  slight  compared  with  the 
dangers  of  eclampsia.  If  the  operation  is  carried  out  antisepti- 
cally,  and  the  author's  method  is  adopted  of  plugging  the  utero- 
vaginal canal  with  iodoform  gauze  to  control  the  frequent  atonic 
secondary  hsemorrhages,  the  mortality  from  eclampsia  has  already 
been  proved  to  be  less  after  delivery  under  deep  anaesthesia  than 
after  spontaneous  delivery.  The  mortality  after  operative  empty- 
ing of  the  uterus  will,  he  believes,  still  go  down  markedly  if  dehvery 
is  effected  whenever  possible  at  once  after  the  first  fit  noticed.  The 
immediate  emptying  of  the  uterus  is,  in  his  opinion,  indicated  in 
any  stage  of  pregnancy,  because  eclampsia  always  kills  the  foetus 
in  the  first  seven  months,  either  directly  or  by  inducing  premature 
labor.  Diihrssen 's  rather  radical  methods  are  not  generally 
approved.     I  shall  illustrate  this  point  by  citing  a  few  cases: 

Case  I.  Mrs.  B.,  aged  twenty-one.  I  para.  Seven  and  one-half  months 
advanced  in  pregnancy.  Suddenly  seized  with  convulsions.  Dr.  Charles 
J.  Hastings  was  summoned.  Administered  morphine  hypodermically 
and  a  copious  cathartic  enema,  also  a  little  chloroform  during  convul- 
sions. Met  Dr.  Hastings  in  consultation  after  six  convulsions.  Xo  signs 
of  labor,  os  uteri  small,  and  cervical  canal  apparently  intact.  Induc- 
tion of  premature  labor  considered  but  postponed  for  the  time  being. 
Altogether  thirteen  convulsions  between  2  v.  m.  and  midnight;  none 
after.  Free  catharsis  kept  up  with  saturated  solution  of  Epsom  salts 
after  patient  became  conscious.  Patient  remained  in  bed.  Five  days 
after  labor  came  on  spontaneously  and  progressed  favorably.  No  fur- 
ther convulsions.     Babe  still-born.     Patient  made  a  good  recovery. 


308    PEEGNAFCY  AND  THE  PUEEPERIUM 

This  was  a  case  where  men  holding  opposite  opinions,  such  as 
those  I  have  referred  to,  would  have  disagreed.  Duhrssen  and  his 
school  would  have  said :  ' '  Empty  the  uterus  at  once. "  Charpen- 
tier,  and  those  who  agree  with  him,  would  have  said:  "Do  not 
interfere;  leave  the  case  to  Nature  if  possible." 

My  own  practise  is  to  abstain  from  interference  if  possible,  par- 
ticularly with  such  conditions  as  here  existed.  The  induction  of 
premature  labor,  with  a  cervical  canal  apparently  intact,  would 
entail  an  amount  of  violence  which  I  think  unadvisable  if  it  can 
be  avoided.  I  prefer,  in  the  first  place,  to  try  the  effects  of  mor- 
phine and  free  catharsis,  with  perhaps  chloroform  and  chloral  ad- 
ministered as  before  described.  In  at  least  a  large  proportion  of 
cases  thus  treated,  the  induction  of  premature  labor  is  not  re- 
quired. 

Case  II.  Very  shortly  after  seeing  this  patient  with  Dr.  Hastings  I 
saw  a  patient  in  the  Burnside  a  few  minutes  after  her  first  convulsion. 
While  examining  her  a  second  convulsion  occurred.  Chloroform  admin- 
istered. No  dilatation  of  the  os,  but  cervical  canal  had  apparently  dis- 
appeared. The  OS  appeared  to  be  to  a  certain  extent  at  least  dilatable, 
so  I  decided  to  make  an  attempt  to  dilate.  The  patient  thoroughly 
anaesthetized,  parts  easily  dilated,  podalic  version,  living  child  easily  ex- 
tracted in  a  few  minutes.  Two  convulsions  after.  Patient  made  a  good 
recovery. 

In  this  case  it  happened  that  the  emptying  of  the  uterus  in  the 
way  described  was  a  very  simple  and  easy  matter.  Under  such 
circumstances  I  think  it  always  better  to  empty  the  uterus.  In  the 
majority  of  cases,  however,  when  convulsions  come  on  during  preg- 
nancy the  induction  of  premature  delivery  is  not  so  simple  a  matter. 

Case  III.  I.  S.,  aged  eighteen.  I  para.  Burnside.  At  or  near  full 
term.  Headache  and  albuminuria.  Free  catharsis  soon  established. 
Notwithstanding  this  convulsions  occurred  shortly  after.  Treatment, 
morphine  ^  grain  hypodermically.  Pulse  showed  high  tension,  so  one 
hour  after  gave  morphine  I  grain  and  tincture  of  veratrum  viride  20 
minims.  Pulse  tension  still  high;  convulsions  continuing.  Two  hours 
after  last  injection  another  ^  grain  of  morphine  with  15  minims  of 
tincture  veratrum  viride.  Four  hours  after,  morphine  |  grain  and  vera- 
trum viride  10  minims.  Pulse  tension  diminished  slightly  but  rate  still 
rapid.  It  appeared  to  me  that  the  veratrum  viride  had  little  or  no  effect. 
Chloral  then  administered  per  enema.  Labor  assisted,  child  extracted  still- 
born.    Patient  recovered. 


ECLAMPSIA  309 

In  this  case  I  had  an  idea  that  45  minims  of  tincture  of  vcra- 
trum  viride  had  Uttlc  or  no  effect.  As  to  the  (juaUty  of  the 
medicine  I  am  now  doubtfuh 

Case  IV.  The  following  case,  reported  by  Mcllwraith,  shows  different 
results.  G.  M.,  aged  nineteen.  I  para.  Delivered  November  17th.  Albumi- 
nuria. Brisk  catharsis  induced.  The  following  day,  convulsions.  Mor- 
phine hypodermically  and  saline  solution  subcutaneously  administered. 
Convulsions  continued  during  the  whole  day,  and  morphine  did  not  appear 
to  control  them.  Catharsis  kept  up  with  calomel  and  compound  powder 
of  jalap.  Fifteen  minims  of  fluid  extract  of  veratrum  viride  hypoder- 
mically. One  hour  after  this  the  pulse  had  fallen  from  120-160  to  60  and 
was  changed  in  character,  becoming  cjuite  soft.  At  the  same  time  profuse 
sweating  occurred.     Rapid  recovery  then  took  place, 

I  have  not  seen  such  good  results  in  any  of  the  six  or  eight  cases 
in  which  I  have  administered  the  veratrum  viride.  However, 
after  so  much  testimony  in  its  favor  a  few  such  results  as  those 
coming  under  my  own  eyes  or  within  my  own  intimate  knowledge 
might  make  me  think  much  more  favorably  of  a  drug  now  so 
popular  in  some  parts  of  this  continent. 

Case  V.  J.  B.,  aged  twenty-six.  II  para.  Burnside.  Two  convul- 
sions before  admission.  Condition  on  admission,  comatose,  breathing 
stertorous,  pupils  sUghtly  contracted,  pufiiness  under  eyes,  oedema  in  feet 
and  legs,  a  small  amount  of  urine,  about  1  ounce,  by  catheter,  loaded 
with  albumin,  convulsions  every  hour  for  fifteen  hours.  Foetus  expelled 
during  thirteenth  convulsion,  dead,  full  term.  Two  convulsions  in  two 
consecutive  hours  after  delivery.  Still  comatose.  Urine  7  ounces  in 
twenty-four  hours.  Treatment,  croton  oil,  morphine,  chloral,  bromides, 
catharsis.  After  administration  of  saline  enemata,  1  pint  every  four 
hours,  quantity  of  urine  increased  to  40  ounces  in  twenty-four  hours. 
On  second  day  after  commencement  of  convulsions  patient  very  weak, 
pulse  140,  respiration  30,  Cheyne-Stokes  type.  Brandy  and  strychnine 
hypodermically  and  nutrient  enemata  instead  of  the  saline.  Gradual 
improvement  third  day;  rapid  improvement  after  patient  became  con- 
scious.    Had  been  comatose  seventy-two  hours.     Good  recovery. 

This  case  is  remarkable  in  showing  the  happy  possibilities  that 
may  exist  even  when  a  patient  is  in  an  apparently  hopeless  con- 
dition. Sometimes  it  is  an  exceedingly  difficult  matter  to  decide 
as  to  prognosis.  One  patient  may  recover  from  a  desperate  con- 
dition while  another  seems  to  die  somewhat  suddenly.  A  cerebral 
haemorrhage  may  account  for  the  death  in  certain  cases  where  the 
symptoms  have  been  comparatively  mild,  but  post-mortems  show 
that  this  is  not  always  the  cause  under  such  circumstances. 


CHAPTER  XIV 

EXTRA-UTERINE  OR  ECTOPIC  PREGNANCY 

In  Parry's  remarkable  book  on  extra-uterine  gestation,  pub- 
lished in  1875,  we  find  the  following  appeal  to  surgeons : 

"A  bleeding  vessel,  through  which  the  red  stream  of  life  is 
rushing  away,  can  be  ligated.  A  gangrenous  limb,  which  is  de- 
stroying its  possessor  by  sending  its  poisonous  emanations  to  the 
remotest  regions  of  his  body,  can  be  amputated.  A  cancerous 
breast,  which  is  sapping  the  vitality  of  its  victim  hour  by  hour,  can 
be  removed  with  the  prospect  of  temporary  relief.  An  aneurysm, 
that  places  life  in  constant  jeopardy,  can  often  be  cured  by  proxi- 
mal or  distal  ligation.  The  tumultuous  motion  of  a  heart  organi- 
cally diseased  may  be  quieted  till  Nature  restores  the  balance,  after 
which  the  person  may  enjoy  a  long  and  even  a  useful  life.  Even 
phthisis  now  counts  its  many  cures ;  but  here  is  an  accident  which 
may  happen  to  any  wife  in  the  most  useful  period  of  her  existence, 
which  good  authorities  have  said  is  never  cured  and  for  which  even 
in  this  age,  when  science  and  art  boast  of  such  high  attainments,  no 
remedy  either  medical  or  surgical  has  been  tried  with  a  single  suc- 
cess. From  the  middle  of  the  eleventh  century,  when  Albucasis 
described  the  first  known  case  of  extra-uterine  pregnancy,  men 
have  doubtless  watched  the  life  ebb  rapidly  from  the  pale  victim 
of  this  accident,  as  the  torrent  of  blood  is  poured  into  the  abdominal 
cavity,  but  have  never  raised  a  hand  to  help  her.  Surely  this  is 
an  anomaly  and  it  has  no  parallel  in  the  whole  history  of  human 
injuries.  The  fact  seems  incredible,  for  if  one  life  is  saved  by  active 
interference  it  may  be  triumphantly  pointed  to  as  the  first  and  only 
instance  of  the  kind  on  record.  In  the  whole  domain  of  surgery — 
for  we  can  not  look  to  other  than  surgical  measures  under  the  cir- 
cumstances— there  is  now  left  no  field  like  this.  The  only  remedy 
that  can  be  proposed  to  rescue  a  woman  under  these  unfortunate 
circumstances  is  gastrotomy,  to  open  the  abdomen,  tie  the  bleed- 
ing vessels,  or  to  remove  the  sac  entire." 
310 


VARIETIES  311 

Although  here  Parry  actually  tells  the  surgeon  exactly  what  he 
should  do  in  a  case  of  rupture  of  an  ectopic  gestation  sac,  yet  for 
years  no  one  acted  on  his  advice.  In  eight  years,  however.  Parry's 
challenge  was  accepted  by  Lawson  Tait,  at  that  time  undoubtedly 
the  greatest  living  abdominal  surgeon,  who  deliberately  operated 
for  tubal  rupture  in  1883. 

The  following  is  a  brief  report  of  an  interesting  case : 

On  a  cold  winter  night,  about  six  years  ago,  a  woman  lay  ill  in  a  poor 
tenement  house,  east  of  the  Don  river,  in  Toronto.  During  the  day  she 
was  working  as  usual  and  looking  after  her  yotmg  infant,  fifteen  months 
old.  In  the  evening  she  had  a  sudden  attack  of  extreme  pain  with  all  the 
signs  of  collapse.  Toward  midnight  she  was  seen  by  Dr.  Rowan  who  sent 
for  Dr.  James  F.  W.  Ross.  When  the  latter  arrived  he  found  the  patient 
blanched  and  collapsed,  cold  extremities,  pulseless,  or  almost  so,  at  the 
WTist.  There  could  be  no  doubt  as  to  her  condition.  She  was  fast  bleed- 
ing to  death  after  a  rupture  of  an  ectopic  gestation  sac.  Was  it  possible 
to  save  her  life?  Ross  decided  to  give  her  a  chance,  the  only  one  left,  by 
abdominal  section  and  ligation  of  the  bleeding  vessels.  He  gave  his 
directions;  one  to  telephone  the  hospital  to  have  everything  in  readiness, 
another  to  summon  me.  Ross  gave  the  baby  to  a  neighbor  to  look  after, 
took  the  patient  in  his  arms,  carried  her  to  his  carriage,  and  brought 
her  to  the  hospital.  During  this  momentous  journey  he  feared  that 
every  moment  might  be  her  last.  When  I  reached  the  hospital  the 
patient  was  on  the  table — not  dead — that  is  about  all  one  could  say. 
Would  I  sanction  an  abdominal  section?  Yes.  In  ten  minutes  the 
operation  was  completed,  the  woman  made  a  good  recovery  and  is  alive 
to-day. 

One  may  learn  from  this  report  that  it  is  not  necessary  to 
travel  far  to  find  examples  of  deeds  of  daring,  deeds  of  skill,  deeds 
of  love.  The  treatment  of  accidents  incidental  to  ectopic  ges- 
tation forms  probably  the  grandest  triumph  of  modern  obstetrical 
surgery. 

Definitions. — Extra-uterine  pregnancy  means  pregnancy  where 
the  impregnated  ovum  remains  and  is  developed  outside  the  uterus. 
This  definition  is  not  always  correct,  because  the  ovum  may  be 
developed  in  that  portion  of  the  tube  which  is  passing  through  the 
wall  of  the  uterus — known  as  the  interstitial  or  tubo-uterine  preg- 
nancy. Ectopic  pregnancy — i.  e.,  misplaced  pregnancy — is  the 
correct  term. 

Varieties. — Primary.  Referring  to  complete  (?)  or  partial  de- 
velopment of  o\aim  where  it  is  fertilized  and  retained. 


312     EXTKA-UTEEINE    OR    ECTOPIC    PEEGNAIsTCY 

Varieties  of  primary  ectopic  pregnancy.  (a)  Tubal — includ- 
ing tubo-uterine  or  interstitial.      (6)  Ovarian — exceedingly  rare. 

For  practical  purposes  we  may  consider  that  all  ectopic  preg- 
nancies are  primarily  tubal. 

Secondary. — When  rupture  of  the  tube  occurs  and  the  foetus  is 
developed  in  a  new  position. 

Varieties  of  secondary  ectopic  pregnancy:  (a)  Abdominal  or 
intraperitoneal.  When  the  foetus  surrounded  by  its  unruptured 
amnion  is  developed  in  the  abdominal  cavity,  (h)  Broad  liga- 
ment, intraligamentous — or  extraperitoneal.  When  the  lower  bor- 
der of  the  tube  ruptures  and  the  foetus  is  developed  between  the 
folds  of  the  broad  ligament  outside  the  peritoneal  cavity. 

Frequency. — The  frequency  of  ectopic  gestation  is  thought 
by  some  to  be  1  in  500  pregnancies^  It  is  probably  much  more 
frequent. 

Course  of  Ectopic  Gestation. — Clinically,  the  course  of  ectopic 
gestation  is  as  follows :  The  woman  is  pregnant,  but  the  fertilized 
ovum,  or  gestation  sac,  is  in  the  tube.  This  causes  no  character- 
istic symptoms  for  a  time.  The  sac  soon  becomes  too  large  for  the 
tube,  and  in  the  first  or  second  month,  or  perhaps  the  third,  the 
tube  is  ruptured.  When  the  rupture  is  on  the  front,  back,  or  upper 
side  of  the  tube  the  embryo  passes  into  the  peritoneal  cavity,  to- 
gether with  more  or  less  blood  from  the  torn  vessels.  When  the 
rupture  is  on  the  under  side  of  the  tube  the  embryo  passes  between 
the  two  layers  of  the  broad  ligament  and  with  it  a  certain  amount 
of  blood.  In  this  intraligamentous  variety  the  embryo  and  col- 
lections of  blood  are  extraperitoneal.  If  the  patient  survives,  the 
embryo*  may  be  fully  developed  beneath  the  peritonaeum,  its  layers 
(especially  the  posterior)  being  more  or  less  stripped  from  the  ab- 
dominal parietes ;  or,  the  ligamentous  covering  may  rupture  at  any 
time  between  the  twefth  week  and  full  term,  allowing  the  contents 
to  pass  into  the  general  peritoneal  cavity.  Frequently  the  embryo 
dies  early,  before  the  sac  has  become  large  enough  to  rupture  the 
tube,  and  a  mole  results. 

Etiology. — The  supposed  causes  of  ectopic  pregnancy  are : 

1.  Salpingitis — inflammation  of  the  mucous  membrane  of  the 
Fallopian  tubes,  causing  destruction  of  the  ciliated  epithelium  lin- 
ing the  tube. 

2.  Accidental  obstruction  of  the  tubes  from  pressure  of  tumors 
or  parametric  inflammatory  products, 


PEIMARY   ECTOPIC    GESTATION  313 

3.  Atrophic  condition  of  the  tube,  either  congenital  or  due  to 
hyperinvohition  after  a  former  labor. 

Many  obstetricians  think  that  it  is  generally  due  to  preexisting 
gonorrhoeal  salpingitis.  Without  discussing  this  subject  now  in 
detail  it  may  be  stated  that  a  physician  should  refrain  from  decid- 
ing off-hand  that  old  gonorrhoea  is  the  cause  of  this  condition. 
The  physician  may  be  wrong  in  giving  such  a  cause,  and  may  at  the 
same  time  do  a  great  injustice  to  his  patient,  her  husband,  or  both. 

Many  authorities,  including  Lawson  Tait  and  Berry  Hart, 
believe  that  tubal  disease  must  precede  tubal  pregnancy,  while 
others,  including  Bland  Sutton,  Martin,  John  Taylor,  and  Clarence 
Webster  believe  that  pregnancy  may  occur  in  a  healthy  tube. 

PRIMARY  ECTOPIC   GESTATION 

Early  History  of  Tubal  Pregnancy. — The  early  hfe  history  of 
tubal  pregnancy,  so  far  as  it  is  known,  is  admirably  described  by 
John  W.  Taylor.  According  to  him  we  have  to  consider  especially 
three  things:  1.  The  attachment  of  the  ovum.  2.  The  increased 
vascularity  of  the  parts  affected.  3.  The  swelling  produced  by  the 
growing  pregnancy. ' 

The  ovum  becomes  embedded  in  the  mucous  membrane  of  the 
tube  about  as  it  normally  does  in  the  uterine  decidua.  Whether 
there  be  any  true  decidual  tissue  formed  in  the  tube  or  not,  it  is 
generally  admitted  that  a  special  zone  of  mucous  membrane  differ- 
entiates into  a  potential  decidua  serotina,  and  that  the  chorionic 
villi  become  developed  in  this  zone.  As  this  development  goes  on 
the  ovum  soon  becomes  somewhat  strongly  attached  at  the  placen- 
tal site,  the  blood-vessels  in  the  part  all  become  much  enlarged,  the 
branches  of  the  ovarian  artery  and  the  uterine  artery  are  found  to 
be  greatly  dilated.  This  hyperaemia  is  very  important  because 
through  it  nourishment  is  afforded  to  the  growing  o^1ml.  There 
is  with  it,  however,  an  element  of  danger  in  case  of  rupture  when 
the  great  hyperaemia  is  apt  to  cause  excessive  haemorrhage. 

The  ovum  grows  somewhat  rapidly,  distends  the  tube  in  such  a 
way  that  a  globular  swelling  may  be  felt  on  one  side  of  the  uterus. 
At  the  same  time  certain  changes  are  going  on  in  the  uterus ;  it  be- 
comes slightly  increased  in  size  and  the  uterine  decidua  is  formed 
within  it  (Fig.  119).  After  the  death  of  the  o^^.lm  this  decidua 
passes  away  from  the  uterus ;  it  may  be  in  shreds,  but  it  is  some- 


314     EXTRA-UTERIFE    OR    ECTOPIC    PREGNANCY 


times  passed  entire  as  a  perfect  cast  of  the  interior  of  the  uterus 
(Fig.  122),  It  is  important  to  note,  however,  that  in  the  so-called 
membranous  dysmenorrhoea  a  similar  cast  is  sometimes  passed. 

Early  Rupture  of  the  Tube.— Rupture  of  the  tube  is  one  of  the 
most  serious  and  one  of  the  most  common  accidents  connected  with 
ectopic  gestation.  In  the  case  reported  it  was  supposed  by  Ross 
that  the  duration  of  pregnancy  had  been  not  more  than  two  weeks. 
An  interesting  question  arises  in  this  connection.  Is  a  patient 
likely  to  have  as  copious  a  haemorrhage  from  rupture  after  two 

weeks  as  after  ten  weeks  ? 
Frequently  very  early 
ruptures  are  accompa- 
nied by  more  copious 
haemorrhages  than  the 
later  ruptures.  Taylor 
calls  special  attention  to 
this  and  tells  us  that 
early  rupture  of  the  tube 
from  a  pregnancy  of  two 
to  six  weeks  duration  is 
a  special  phenomenon 
which  has  not  received 
the  recognition  and  con- 
sideration it  deserves. 
He  tells  us  that,  as  a 
disease  or  accident,  it 
stands  alone,  there  being 
no  warning  of  danger,  frequently  no  physical  signs  of  any  sort, 
until  symptoms  of  collapse  suddenly  appear  from  copious  bleed- 
ing. In  Ross's  case  the  operation  was  done  in  about  ten  hours 
after  symptoms  appeared.  In  these  cases  of  early  rupture,  with- 
out operative  interference,  death  usually  occurs  in  from  twelve 
to  forty-eight  hours. 

Cullingworth  reports  a  case  where  a  patient  died  within  three 
hours  from  the  beginning  of  the  attack. 

Generally,  after  rupture  into  the  peritoneal  cavity,  the  haemor- 
rhage is  "diffuse  " — that  is,  the  blood  passes  into  those  parts  of  the 
peritoneal  cavity  where  there  is  the  least  resistance.  Occasionally, 
however,  we  find  a  more  favorable  issue — that  is,  the  formation  of 
a  definite  haematocele. 


Fig,  118,- — Ectopic  Gestation,  showing 
Rupture  of  the  Tube  and  the  Corpus 
LuTEUM.     (Tor.  Univ.  Museum.) 


PEIMARY    ECTOPIC    GESTATION 


315 


Tubal  Mole. — In  certain  cases  the  embryo  dies  without  causing 
rupture  of  the  tube.  Such  death  is  probably  caused  by  the  pour- 
ing out  of  blood  into  the  space  between  the  amnion  and  chorion. 
Under  such  circumstances  the  dead  egg,  or  blighted  ovum,  becomes 
a  mole.  The  history  of  this  mole  is  interesting.  One  might  sup- 
pose that  such  early  death  of  the  embryo  should  make  things  com- 
paratively safe.  This  is  not  the  case,  however,  as  the  presence  of 
this  mole  within  the  tube  generally  causes  serious  trouble. 

Tubal  Abortion. — The  mole  is  sometimes  extruded  into  the 
peritoneal  cavity,  such  extrusion  causing  tubal  abortion.  It  is 
probable  that  tubal  abortion  (extrusion  of  ovum  from  the  tube) 
takes  place  in  only  a  small  proportion  of  cases. 

Generally,  the  mole  remains  strongly  attached  to  that  portion 
of  the  inner  surface  of  the  tube  where  the  placenta  would  have  been 


Fig.  119. — Ectopic  Gestation,  Rupture. 

Immigrant  found  dying  from  haemorrhage  at  Union  Station,  Toronto.  Part  of 
anterior  wall  of  uterus  removed;  d,  thickened  decidua;  r,  site  of  rupture.  (Jolm 
Caven,  Tor.  Univ.  Museum.) 


developed  if  pregnancy  had  not  been  interrupted.     As  Taylor  ex- 
presses it,  the  mole  clings  to  the  tube  like  a  pedunculated  polypus, 
the  mole  being  free  excepting  at  the  one  point  of  attachment. 
This  mole  is  a  continuous  source  of  irritation  and  causes  great 


316     EXTEA-UTEEINE    OE    ECTOPIC    PEEGNANCY 

hypersemia  in  the  surrounding  tissues.  As  a  consequence  of  this 
hypersemia  we  are  apt  to  have  numerous,  and  sometimes  danger- 
ous, haemorrhages  from  the  tube  into  the  peritoneal  cavity,  forming 
the  most  common  variety  of  intraperitoneal  hsematocele. 

Some  authors  give  the  following  definition : 

Tubal  abortion  is  complete  or  partial  separation  of  the  ovum 
from  the  tube  wall.  According  to  this  definition  there  are  two 
kinds  of  tubal  abortion:  (1)  Incomplete  abortion— partial  detach- 
ment of  the  ovum.  (2)  Complete  abortion — complete  detachment 
and  extrusion  of  the  ovum  from  the  tube. 

Later  Rupture  of  the  Tube. — Later  rupture  may  occur  at  any 
time  from  the  first  month  onward,  but  is  most  common  from  the 
second  to  the  fourth  month  (Taylor).  Later  rupture  is  more  com- 
mon when  the  egg  is  situated  in  the  middle  or  outer  portion  of  the 
tube ;  in  this  position  it  is  more  apt  to  open  up  to  some  extent  the 
two  layers  of  the  meso-salpinx,  thus  causing  delay  of  the  rupture. 
Rupture,  under  such  circumstances,  when  it  does  take  place  is 
sufficiently  serious,  but  not  so  rapidly  ''fatal  without  warning" 
as  it  is  in  the  case  of  early  rupture.  The  haemorrhage  is  sometimes 
very  slight  if  not  altogether  absent.  When  the  placenta  is  sep- 
arated or  torn  during  the  rupture  the  bleeding  is  severe,  but  when 
it  is  not  involved  the  haemorrhage  will  come  from  the  ruptured 
tube  alone  and  may  be  very  slight.  Even  when  the  placenta  is 
involved  the  haemorrhage  seldom  causes  death  within  a  short  time. 

HEMORRHAGES  DUE   TO   ECTOPIC   GESTATION 

These  various  forms  of  hasmorrhage  may  now  be  considered 
in  detail : 

Diffuse  or  Unlimited  Haemorrhages. — As  before  stated,  the 
haemorrhage  after  rupture  of  the  tube  is  frequently  so  copious  that 
there  is  not  time  for  the  blood  to  become  surrounded  by  any 
adventitious  capsule. 

Intraperitoneal  Haematocele. — This  form  of  blood  tumor  is 
very  interesting  and  much  better  understood  now  than  it  was 
twenty  years  ago.  It  is  occasionally  due  to  other  causes,  but, 
practically,  we  may  consider  that  intraperitoneal  haematocele  is 
due  in  some  way  or  other  to  tubal  gestation.  We  may  accept 
Taylor's  statement  that  rupture  of  the  tube  is  especially  liable  to 
be  followed  by  the  diffuse  bleeding;  while  haemorrhage  from  an 


PEIMARY    ECTOPIC    GESTATION 


317 


unruptured  tube  containing  a  mole  is  the  most  common  cause  of 
the  intraperitoneal  ha3matocele. 

The  haematocele  of  the  tubal  mole  forms  slowly  through  the 
more  or  less  continuous  blood  drip  from  the  fimbriated  end  of  the 
tube,  giving  time  for  consolidation  of  the  outer  layer  of  blood,  pro- 
ducing a  sort  of  capsulation. 

The  unstable  peritoneal  haematocele  is  a  very  indefinite  thing. 
A  considerable  collection  of  blood  within  the  peritoneal  cavity 
may  become  rapitUy  and   completely  absorbed.     When  not  ab- 


FiG.  120. — Interstitial,  Ectopic  Pregnancy,  Rupture. 

Healthy  woman  died  after  an  illness  of  a  few  hours.  Post-mortem  examination 
made  by  order  of  coroner  to  ascertain  cause  of  death.  (N.  A.  Powell,  Tor. 
Univ.  Museum.) 


sorbed  the  blood  may  fill  the  pouch  of  Douglas  and  rise  above  the 
uterus.  It  may  become  covered  by  a  fibrinous  capsule,  part  of 
which  is  formed  by  surrounding  viscera  matted  together  by  adhe- 
sions. The  collection  of  blood  being  thus  shut  off  from  the  general 
cavity  of  the  peritonaeum  becomes  the  haematocele.  As  Taylor 
tells  us,  a  fresh  haemorrhage  may  break  through  the  weak  capsule 
and  thus  become  profuse.  Other  things  may  happen,  however. 
The  haematocele  may  be  absorbed,  or  it  may  become  septic  and 
transformed  into  an  abscess. 


318     EXTEA-UTERINE    OE    ECTOPIC    PREGNANCY 

Extraperitoneal  Haematocele  or  Broad  Ligament  Haematoma. 

— After  rupture  of  the  lower  border  of  the  tube  more  or  less  haem- 
orrhage takes  place,  and  the  blood  thus  poured  out  forms  an  extra- 
peritoneal haematocele.  Haematoma  of  the  broad  ligament  may 
occasionally  follow  certain  pelvic  operations,  especially  those 
which  involve  ligature  of  the  broad  ligament.  It  may  also  occa- 
sionally be  found  in  connection  with  abortion,  labor,  and  irregular 
menstruation. 

In  a  large  proportion  of  cases  the  foetus  soon  perishes  after  it 
passes  below  the  tube  and  the  blood  poured  out  is  slowly  absorbed. 
The  embryo  is  frequently  absorbed  at  the  same  time. 

I  have  had  two  cases  of  broad  ligament  haematocele  (in  one  of 
which  the  patient  was  seen  by  Ross,  in  the  other  by  Temple)  in 
which  absorption  took  place  somewhat  rapidly  and  completely, 
so  that  both  patients  made  a  perfect  recovery  within  a  few  weeks. 

Diagnosis  of  Diffuse  Intraperitoneal  Haemorrhage  and  Stable 
Haematoceles. — Although  the  outpour  of  blood  with  or  without 
the  formation  of  a  stable  haematocele  is  simply  an  incident  in  the 
history  of  an  ectopic  pregnancy,  the  blood-mass  often  becomes  the 
all-important  matter  both  for  diagnosis  and  treatment. 

Pain.  One  of  the  most  common  symptoms  associated  with 
haematocele  is  pain,  which  frequently  comes  on  suddenly  and  is 
often  accompanied  with  vomiting.  Sometimes  the  tenderness  of 
the  abdomen  is  extreme.  The  pain,  however,  soon  abates  in  the 
majority  of  cases,  and  such  abatement  may  cause  the  patient  to 
think  that  she  is  not  seriously  ill,  and  may  cause  the  physician  to 
overlook  the  extreme  gravity  of  the  woman's  condition. 

Uterine  hcemorrhage  is  also  nearly  always  associated  with  the 
haematocele.  The  blood  is  generally  dark  in  color,  moderate  in 
amount,  and  steady  in  flow. 

Decidua  in  vaginal  discharges  is  sometimes  found.  It  is  thicker 
than  that  expelled  in  membranous  dysmenorrhoea. 

Rise  of  temperature  is  a  much  more  common  symptom  (accord- 
ing to  Cullingworth)  than  is  generally  supposed. 

The  pulse  is  increased  in  frequency. 

Menstruation.  One  period  has  been  missed,  as  a  rule,  and 
menstruation  has  subsequently  been  irregular. 

Physical  Signs  of  Diffuse  Intraperitoneal  Haemorrhage.  — 
When  there  has  been  diffuse  haemorrhage  the  signs  are  very  ob- 
scure.    We  have  not,  as  a  rule,  the  usual  signs  of  the  presence  of  a 


PEIMAEY    ECTOPIC    CESTATTON" 


319 


free  fluid  in  the  peritoneal  cavity.  The  tliick  tarry  or  coated 
blood  which  is  present  does  not  give  the  signs  ordinarily  found  in 
ascites.  It  is  quite  true,  however,  that  change  of  position  does 
sometimes  cause  a  change  in  the  area  of  dulness  found  in  the  flanks, 
and  fluctuation  may  occasionally  be  detected.  The  symptoms  of 
internal  haemorrhage  are  generally  sufficiently  plain  without  the 
physical  signs. 

Vaginal  Examination.  The  blood  which  is  poured  out  is  likely 
to  soon  fin  the  pouch  of  Douglas.  This  causes  a  "full  and  boggy 
condition"  which  can  be  detected  by  the  examining  fingers. 

Physical  Signs  of  Stable  Pelvic  Haematocele. — An  irregular  lump 
is  generally  easily  detected  by  bimanual  examination.     Before 


Fig.  121. — Tubal  Abortion,  Ovum  being  extruded  through  Fimbriated 
Extremity  (Kelly).      x  1. 


maKing  an  examination  one  should  be  sure  that  the  bladder  and 
rectum  are  emptied.  The  bimanual  examination  should  be  both 
vagino-abdominal  and  recto-abdominal.  The  recto-abdominal  is 
generally  the  more  useful  in  detecting  and  defining  the  smaller 
haematoceles.  The  "boggy"  condition  may  be  evident  or  the 
mass  may  be  quite  hard,  especially  after  a  time.  This  swelling  is 
more  or  less  tender  and  immovable.  It  is  situated  behind  the 
uterus,  pushing  this  organ  forward  and  generally  to  one  side.  It 
distends  the  pouch  of  Douglas,  depresses  the  vaginal  vault,  bulges 
into  the  rectum,  and  when  larger  extends  upward  into  the  abdo- 
23 


320     EXTRA-UTEEINE    OR    ECTOPIC    PREGNANCY 

men.  The  upper  border  may  be  as  high  as  the  umbilicus  and  is 
generally  irregular  in  shape  and  higher  on  one  side  than  on  the 
other.  In  the  early  stages — i.  e.,  soon  after  the  outpouring  of 
blood — it  is  difficult  to  outline  the  swelling,  on  account  of  the  gen- 
eral abdominal  distention,  the  great  tenderness,  and  the  rigidity  of 
the  abdominal  walls.  As  these  symptoms  subside  and  as  the  outer 
portion  of  the  mass  becomes  hardened,  the  irregular  outline  of  the 
lump  can  easily  be  detected. 

Although  in  a  majority  of  cases  the  free  blood  soon  finds  its 
way  into  the  pouch  of  Douglas  it  does  not  always  flow  to  this  most 
dependent  portion  of  the  abdominal  cavity  by  gravitation.  The 
hsematocele  is  not  infrequently  found  surrounding  the  aperture 
through  which  the  blood  is  escaping,  especially  in  case  of  ' '  blood 
drip  ' '  from  the  fimbriated  extremity  of  the  tube  caused  by  irrita- 
tion of  the  tubal  mole. 

Extraperitoneal  Haematocele  or  Broad  Ligament  Haematoma. 
— The  blood  is  confined  within  a  fairly  definite  space  between  the 
peritonaeum  above  and  the  pelvic  fascia  below.  It  strips  up  the 
peritonaeum  to  some  extent,  but  such  separation  is  so  limited  and 
slow  as  to  prevent  anything  like  diffuse  haemorrhage. 

The  blood  is  poured  first  on  one  side  and  the  lump  may  be 
easily  felt.  Sometimes  the  blood  is  forced  over  to  the  other  side. 
If  one  has  the  opportunity  to  examine  daily  before  and  during  the 
outpouring  of  blood  he  can  detect  perhaps  a  small  lump  close  to  the 
uterus  (the  unruptured  ectopic  pregnancy).  After  extraperito- 
neal rupture  a  large  mass  is  easily  felt  as  it  fills  (or  nearly  so) 
one  side  of  the  pelvis  and  pushes  the  uterus  over  to  the  other 
side.  On  the  following  day  one  may  find  that  the  posterior  layer 
of  the  broad  ligament  is  stripped  from  the  uterine  wall,  allow- 
ing some  Jolood  to  go  to  the  other  side  of  pelvis.  The  shape  of 
the  tumor  is  like  a  "jelly-fish,"  rounded  above,  concave  below 
(Lawson  Tait). 

When,  in  exceptional  cases,  the  effusion  rises  above  the  pelvic 
brim  a  rounded,  well-defined  tumor  may  be  felt.  Below  the  mass 
slopes  off  outward,  appearing  to  merge  into  the  pelvic  wall.  Per 
rectum  it  seems  as  if  a  half  ring  were  pressing  on  the  rectum,  flat- 
tening it  backward,  ^ 

Differential  Diagnosis. — In  making  a  diagnosis,  especially  of  the 
intraperitoneal  variety  of  haematocele,  one  should  keep  in  mind 
the   following   conditions :    threatened   abortion,   retroversion   of 


SECONDARY    ECTOPIC    GESTATION"  321 

a  gravid  uterus,  salpingitis  or  salpingo-oophoritis,  ovarian  cyst 
with  sudden  twisting  of  the  pedicle,  and  fibro-myoma. 

SECONDARY  ECTOPIC   GESTATION 

Tube -Abdominal   or  Abdominal   or  Ventral   Pregnancy. — The 

secondary  forms  of  ectopic  pregnancy  are  always  derived  from  the 
primary  form.  When  the  foetus,  after  rupture  of  the  tube,  passes 
into  the  abdominal  cavity  and  becomes  developed  there  we  have 
one  of  the  secondary  forms  of  ectopic  pregnancy,  which  is  known 
as  abdominal  or  ventral  pregnancy.  Some  have  thought  that  a 
young  fcBtus  passing  from  the  tube  into  the  abdominal  cavity  must 
of  necessity  be  destroyed  by  the  peritoneal  secretions,  and  that, 
therefore,  all  ventral  pregnancies  must  have  been  originally  sub- 
peritoneal or  intraligamentous.  It  was  supposed  by  Tait,  Sutton, 
and  others  that  the  foetus  after  remaining  outside  the  peritonaeum 
until  the  seventh  or  eighth  month  of  pregnancy  had  become  devel- 
oped to  such  an  extent  that  it  could  successfully  resist  the  efforts 
of  digestion  by  the  fluids  of  the  peritoneal  cavity.  It  was  also 
supposed  that  about  this  time  there  was  rupture  of  the  broad 
ligament  cyst,  allowing  the  foetus  to  pass  into  the  general  peritoneal 
cavity. 

I  think  Taylor  is  correct  in  saying  that  after  the  later  rupture 
of  the  tube  (that  is,  in  the  third  or  fourth  month)  the  foetus  may 
pass  directly  into  the  peritoneal  cavity  and  be  developed  there, 
being  protected  from  the  action  of  the  fluids  by  the  unruptured 
membranes,  especially  the  amnion.  The  enveloping  amnion  being 
nearly  transparent  is  not  easily  seen,  and  has  consequently  been 
often  overlooked,  but  careful  examination  will  probably  show  that 
it  is  present  in  every  case  of  abdominal  pregnancy. 

Tube -Ligamentous  Pregnancy  or  Broad  Ligament  Pregnancy. 
— This  comes  about  in  the  following  way:  As  the  fructified  ovum 
grows  the  tube  expands  and  in  doing  so  separates  to  some  extent 
the  mesosalpinx  as  before  mentioned.  The  lower  edge  of  the  tube 
is  thus  pressed  toward  the  loose  connective  tissue  which  there 
exists,  and  at  a  certain  time  is  ruptured.  This  allows  the  foetus 
to  escape  into  this  connective  tissue,  while  the  placenta  retains, 
in  part  at  least,  its  connection  with  the  tube  as  in  the  abdominal 
pregnancy.  In  the  one  case  the  foetus  passes  downward  and  is 
developed  beneath  the  peritonaeum,  while  in  the  other  it  passes 


322     EXTRA-UTEEINE    OE    ECTOPIC    PREGNANCY 

upward  and  is  developed  within  the  peritonaeum ;  in  both  cases  the 
placenta  is  to  a  large  extent  stationary. 

DIAGNOSIS  OF  ECTOPIC   GESTATION 

Every  physician  who  is  engaged  in  obstetrical  practise  should 
endeavor  to  become  an  expert  diagnostician  as  to  all  varieties  and 
all  phases  of  ectopic  pregnancy.  The  obstetrician  meets  with  such 
cases  as  a  rule  before  the  gynaecologist  or  surgeon.  The  obstet- 
rician should  also  be  prepared  to  operate  in  certain  cases  of  emer- 
gency. When,  for  instance,  an  operation  is  urgently  required 
minutes  frequently  count.  A  practitioner  in  the  country  can  not 
wait  for  hours  or  days  until  he  procures  an  expert  from  a  neigh- 
boring city  without  in  certain  cases  sacrificing  the  patient's  life. 
Remember  Cullingworth's  patient,  the  wife  of  a  physician  by  the 
way,  who  died  in  three  hours  after  the  appearance  of  the  first 
symptoms. 

It  is  usual  in  speaking  of  symptoms  first  to  consider  those 
which  occur  before  rupture  of  the  tube.  Sometimes,  however, 
the  first  symptoms  noticed  are  those  due  to  rupture  of  the  tube 
with  rapidly  following  results  that  are  truly  appalling  in  character. 
In  speaking  in  detail  as  to  diagnosis  I  shall,  therefore,  take  up  first 
the  earliest  rupture. 

Varieties. — The  varieties  may  again  be  mentioned  in  what  may 
be  called  their  chronological  order  as  to  the  appearance  of  the 
symptoms. 

1.  Earliest  rupture  of  the  tube  with  diffuse  haemorrhage  into 
the  abdominal  cavity. 

2.  Unruptured  tubal  pregnancy  with  a  living  ovum  or  with  a 
dead  ovum  or  tubal  mole,  with  perhaps  intraperitoneal  haemato- 
cele  probably  encapsulated. 

3.  Later  rupture  of  the  tube  and  escape  of  foetus  with  either 
diffuse  haemorrhage  into  the  peritoneal  cavity  or  only  slight  haemor- 
rhage with  perhaps  the  formation  of  haematocele  generally  unstable 
in  character;  or,  on  the  other  hand,  a  later  rupture  of  the  tube 
with  escape  of  the  foetus  and  haemorrhage  beneath  and  outside 
the  peritonaeum. 

4.  Growing  pregnancy,  full  term  pregnancy,  or  dead  pregnancy. 

Sjmiptoms  of  Earliest  Rupture. — I  shall  consider  these  symp- 
toms chiefly  from  a  clinical  standpoint,  drawing  largely  from  the 
graphic  descriptions  of  Cullingworth  and  Taylor. 


DIAGNOSIS    OF    KCTOl'JC    OKSTATION  323 

The  si^ns  and  symptoms  are  those  of  acute  and  sudden  abdom- 
inal lesion  pkis  those  of  severe  internal  or  concealed  ha3morrhage. 
The  patient,  during  the  child-bearing  age,  has  been  previously  in 
good  health  and  is  suddenly  seized  with  a  severe  pain  in  the  al)do- 
men  "as  if  something  has  given  way  inside  her."  This  pain  is 
often  accompanied  with  vomiting.  She  soon  becomes  faint  and 
more  or  less  collapsed.  She  probably  lies  down  on  a  couch  or  is 
assisted  to  her  bed.  Along  with  this  pain  there  is  generally  ex- 
treme tenderness  of  the  abdomen.  She  remains  quite  conscious. 
Along  with  the  usual  signs  of  collapse  there  is  a  gradually  increas- 
ing pallor  of  the  surface,  the  patient  at  the  same  time  having  a 
seriously  "passive"  expression. 

Are  these  symptoms  due  to  simple  faintness  or  active  haemor- 
rhage? The  pulse  will  tell.  If  due  to  faintness  the  pulse  when 
found  will  be  slow  and  moderately  full.  If  due  to  serious  haemor- 
rhage the  pulse  increases  in  frequency  (20  to  40  more  than  normal) 
and  becomes  weaker.  This  rapidity  of  the  pulse  is  not  due  to 
nervousness  or  excitement  for  the  patient  is  curiously  self-con- 
tained and  quiet.  The  temperature  soon  becomes  subnormal. 
If  the  haemorrhage  continues  a  colder  grayness  slowly  creeps  over 
the  countenance,  the  voice  becomes  feeble,  sight  dimmed,  the 
fingers  white  and  cold.  The  patient  becomes  restless,  often  sighs 
deeply,  yawns,  and  exhibits  other  signs  of  weariness,  and  if  left 
untreated  gradually  sinks,  maintaining  a  perfectly  clear  intellect 
to  the  last. 

In  making  a  diagnosis  Cullingworth  attaches  much  importance 
to  the  following  points : 

1.  The  previous  good  health  of  the  patient  making  it  highly 
improbable  that  the  symptoms  are  due  to  gastric  or  intestinal  per- 
foration, or  to  rupture  of  an  internal  abscess  or  suppurating  cyst. 

2.  The  gradually  increasing  pallor  of  the  patient  and  the  grad- 
ually rising  pulse  rate  without  corresponding  rise  of  temperature. 

3.  The  extreme  tenderness  of  the  abdomen. 

4.  If  a  menstrual  period  has  been  missed  or  is  overdue  the  diag- 
nosis is  facilitated,  but  regularity  of  menstruation  does  not  exclude 
ectopic  pregnancy.  She  has  perhaps  missed  a  period  which  was 
due  a  few  days  before  the  seizure.  There  was  perhaps  some  dis- 
charge of  blood  from  the  vagina  quite  profuse  for  a  time,  shortly 
before  the  seizure.  Although  there  may  have  been  such  a  dis- 
charge of  blood  the  period  did  not  come  on  properly. 


324     EXTEA-UTERINE    OE    ECTOPIC    PREGNANCY 


Symptoms  of  Unruptured  Tubal  Pregnancy. — In  unruptured 
tubal  pregnancy  the  patient  has  generally  missed  a  menstrual 
period.  This  is  followed  by  irregular  uterine  haemorrhages  not 
similar  to  regular  menstruation.  The  blood  discharged  is  gener- 
ally dark  in  color  and  different  from  the  discharge  in  uterine  abor- 
tion, which  is  often  very  copious  and  accompanied  by  gushes  of 
bright  red  blood.     Considerable  importance  is  attached  by  some 

to  the  passage  of  decidual 
membrane,  but  Ross 
thinks  it  is  not  of  much 
value  in  diagnosis  because 
it  is  generally  extruded  at 
a  somewhat  later  stage  and 
only  after  serious  symp- 
toms have  set  in.  Paroxys- 
mal "bearing  down" pains 
are  frequently  present. 
Breasts  are  frequently  en- 
larged and  tender  as  in 
ordinary  pregnancy. 

Physical  Signs.  —  Pul- 
sating vessels  are  some- 
times felt  in  vaginal  vault 
on  one  side  of  the  uterus. 
A  tubal  tumor  is  found  on 
same  side  generally  close 
to  back  of  uterus,  hard, 
round  and  not  pitted  like 
the  ovary.  At  the  same  time  the  ovary  may  be  made  out  as  dis- 
tinct from  the  tubal  tumor  (Ross).  The  round  ligament  lies  on 
the  median  side  of  the  tumor — i.  e.,  between  the  body  of  the  uterus 
and  the  tumor.  The  tumor  has  a  pedicle  formed  by  a  part  of 
the  tube  and  the  mesosalpinx  holding  the  same  relations  to  the 
uterus,  broad  ligament  and  ovary  as  the  hydrosalpinx  does — that 
is  to  say,  the  body  of  the  uterus  is  well  defined. and  separate  from 
the  tumor  on  its  inner  (median)  side.  The  ovary  is  also  found 
intact  (Kelly). 

Tubo-Uterine  or  Interstitial  Pregnancy. — This  runs  a  shghtly 
different  course  from  the  ordinary  tubal  form.  The  tubo-uterine 
pregnancy  is  very  rare,  while  the  ordinary  tubal  form  is  compara- 


FiG.  122. — Ectopic  Gestation,  Uterine  De- 
ciDUA  expelled  ENTIRE.  (Temple.  Tor 
Univ.  Museum.) 


DIAGNOSIS    OF    ECTOPIC    GESTATION  325 

tively  common.     Ross  met  with  only  one  tubo-utcrine  pregnancy 
in  a  series  of  45  cases ;  Taylor  one  in  42 ;  Tait  one  in  40. 

The  walls  of  the  gestation  sac  are  very  thick  in  tuho-uterine 
pregnancy,  while  they  are  very  thin  in  the  tubal.  While  either 
may  rupture  into  the  peritoneal  cavity  the  tubo-uterine  may  pos- 
sibly rupture  into  the  uterine  cavity  and  be  discharged  through  the 
vagina.  After  rupture  of  a  tubo-uterine  pregnancy  hajmorrhage  is 
apt  to  be  very  severe.  Rupture  of  a  tubo-uterine  pregnancy  is  apt 
to  occur  later  than  in  the  ordinary  tubal  pregnancy,  although  very 
early  rupture  of  the  former  may  occur  as  in  Ross  and  Bryans'  case. 

In  this  case  the  patient  had  missed  one  period.  Sudden  pain 
with  faintness  occurred  at  noon  one  day.  Bryans  sent  patient 
same  afternoon  to  the  hospital  and  placed  her  under  the  care  of 
Ross.  Through  an  unfortunate  misunderstanding  Ross  did  not 
see  her  until  the  following  morning  when  she  was  almost  moribund. 
He  operated,  however,  and  found  the  abdominal  cavity  full  of 
blood.  It  was  very  difficult  to  make  out  the  point  from  which  the 
haemorrhage  was  coming.  Drew  up  one  tube,  found  it  healthy; 
drew  up  the  other  tube,  found  it  healthy,  and  was  for  a  moment  at 
a  loss  to  know  what  to  do.  On  raising  the  uterus  he  found  a  small 
spot  on  the  anterior  wall  behind  the  junction  of  the  round  ligament 
with  the  uterine  fundus.  On  sponging  this  off  he  could  make  out 
distinctly  a  small  cavity  about  the  size  of  a  small  pea  with  dark 
edges,  from  which  the  blood  oozed.  It  was  evidently  a  rupture  of 
an  interstitial  pregnancy  of  very  short  duration.  Patient  died  the 
same  afternoon. 

Later  Rupture  of  the  Tube. — We  have  here:  1.  The  symptoms 
before  the  rupture.     2.  The  symptoms  arising  from  rupture. 

If  one  has  not  seen  the  patient  before  the  onset  of  pain  with 
collapse  he  will  have  learned  nothing  as  to  the  preexistence  of 
tumor,  etc.  He  may,  however,  learn  something  from  the  patient 
or  her  friends  as  to  irregularity  of  menstruation,  nausea,  pains  in 
the  breasts,  and  other  symptoms  of  pregnancy. 

Although  there  may  be  no  symptoms  before  early  rupture, 
excepting  a  slight  delay  in  menstruation,  there  are  generally 
marked  disturbances  before  the  late  rupture.  Menstrual  irregu- 
larity and  pelvic  pain  should  always  make  one  think  of  ectopic 
pregnancy.  If  one  can  detect  by  physical  examination  the  tubal 
tumor  at  the  side  of  the  uterus  he  obtains  confirmatory  evidence. 
If  he  can  not  detect  such  a  tumor  he  should  not  conclude  that  there 


326     EXTEA-UTEKINE    OE    ECTOPIC    PEEGNANCY 

is  no  ectopic  pregnancy.     In  either  case  a  consultation  should  be 
held  as  soon  as  possible. 

The  signs  following  the  later  rupture  are  similar  to  those  before 
referred  to  in  connection  with  early  rupture — i.  e.,  acute  pain  with 
tenderness,  and  collapse  from  loss  of  blood.     As  before  intimated 


Fig.  123. — Ectopic  Gestation,  Broad  Ligament  or  Extraperitoneal. 

Fcetus  and  placenta  removed  at  ten  months;  principal  attachment  of  tumor  to 
right  corner  of  the  uterus;  pedicle  three  inches  long;  Fallopian  tube  and  ovary 
in  pedicle  one  inch  apart;  sac  had  two  layers,  the  outer  thick  and  tough,  pre- 
sumably thickened  peritonaeum  of  broad  ligament,  the  inner  dead  tissue  con- 
taining placenta  firmly  attached  and  membranes  (one  layer  apparently)  easily 
separable  from  outer  layer.  Indian  woman,  in  British  Columbia,  made  a  good 
recovery.      (H.  C.  Wrinch,  Tor.  Univ.  Museum;  see  Can.  Lancet,  Nov.,  1901.) 


the  haemorrhage  in  later  rupture  is  in  a  large  proportion  of  cases 
not  so  severe  as  that  following  the  early  rupture.  It  is  well,  how- 
ever, to  consider  both  forms  equally  dangerous,  although  very 
prompt  action  is  sometimes  more  urgently  needed  after  the  early 
rupture  than  after  the  later. 


DIAGNOSIS    OF    ECTOiMC    GESTATION  327 


DIFFERENTIAL   DIAGNOSIS    OF  TUBAL   PREGNANCY 

Bland  Sutton  states  tlie  following  facts:  Uterine  and  tubal 
pregnancy  are  sometimes  concurrent.  Uterine  pregnancy  some- 
times follows  tubal  variety.  Tubal  pregnancy  may  be  bilateral. 
Tubal  pregnancy  may  be  repeated.  Tubal  pregnancy  and  ova- 
rian or  parovarian  tumors  may  coexist. 

Taylor  says  tubal  pregnancies  may  be  simulated  by  or  mistaken 
for:  1.  Threatened  or  incomplete  abortion.  2.  Intra-uterine  preg- 
nancy complicated  with  pelvic  tumor.  3.  Retroflexion  of  the 
gravid  uterus.  4.  Anteflexion  of  the  gravid  uterus.  5.  Pyosal- 
pinx.  6.  Myoma.  7.  Twisted  pedicle  tumors :  (a)  Of  the  tube, 
(6)  of  the  ovary. 

I  have  made  a  slight  modification  of  Taylor's  list  in  using  the 
words  "  threatened  or  incomplete  "  instead  of  ''simple"  abortion. 

Threatened  or  Incomplete  Abortion. — The  symptoms  of  normal 
pregnancy  and  ectopic  pregnancy  are  similar  in  many  respects.  In 
both  there  may  be  amenorrhoea,  morning  sickness,  pains  in  breasts, 
constipation,  etc.  Symptoms  of  abortion  may  occur  in  either  case 
— viz.,  irregular  uterine  haemorrhages,  passage  of  membranous 
clots,  abdominal  pains,  etc.  We  must  now  rely  on  physical 
signs  as  discovered  by  bimanual  examination  with  bladder  and 
rectum  empty.  Frequently  the  administration  of  chloroform  is 
necessary. 

In  abortion  the  tumor  of  pregnancy  is  central  and  continuous 
with  the  cervix.  There  is  no  uterine  body  apart  from  the  tumor. 
The  back  and  sides  of  the  (uterine)  tumor  are  free  from  any  abnor- 
mal swelling.  There  are  no  pulsating  vessels  felt  in  vaginal  vault 
at  one  side  of  uterus.  The  discharges  of  blood  are  often  copious 
and  bright  red  in  color,  coming  sometimes  in  gushes,  alternating 
with  the  passage  of  clots.  The  uterus  is  enlarged  in  proportion  to 
the  age  of  the  pregnancy. 

In  ectopic  pregnancy  the  tumor  is  on  one  side  of  the  uterus  and 
distinct  from  ovary.  It  is  not  continuous  with  the  cervix.  The 
uterine  body  may  be  felt  apart  from  the  tumor.  The  tumor 
appears  to  be  at  the  side  of  or  behind  the  uterus.  Pulsating  ves- 
sels are  sometimes  felt  in  vaginal  vault.  The  discharges  of  blood 
are  not  generally  copious,  fairly  thick  in  consistence,  steady  in 
their  rate  of  flow  as  long  as  they  last.  The  uterus  is  only  slightly 
enlarged. 


328     EXTEA-UTERINE    OE    ECTOPIC    PREGNANCY 

Intra-Uterine  Pregnancy  Complicated  with  Pelvic  Tumor. — It 

is  well  to  have  the  possibility  of  such  a  condition  always  in  one's 
mind.  It  is  sometimes  impossible  to  reach  a  definite  conclusion 
even  after  a  careful  bimanual  examination.  When  in  doubt  wait 
for  a  time.  If  it  is  found  at  one  or  more  subsequent  examinations 
that  the  uterus  is  enlarging  while  the  adjacent  tumor  remains 
stationary  or  nearly  so,  the  pregnancy  is  intra-uterine. 

Retroflexion  or  Retroversion  of  the  Gravid  Uterus. — A  peri- 
tubal hsematocele  situated  behind  the  uterus  or  a  retro-uterine 
broad  ligament  pregnancy,  as  felt  by  vaginal  examination,  is  very 
similar  to  retroflexion  of  the  gravid  uterus.  By  careful  bimanual 
examination  the  fundus  uteri  can  usually  be  felt  immediately  above 
the  pubes.  A  discharge  of  blood  without  accompanying  labor 
pains  is  more  common  in  ectopic  pregnancy  than  in  a  retrofiexed 
gravid  uterus.  Retention  of  urine  is  more  common  in  retrofiexed 
gravid  uterus. 

The  difficulty  of  differential  diagnosis  is  sometimes  so  great 
that  the  importance  of  the  following  rule  given  by  Taylor  should 
be  recognized :  Never  diagnose  a  gravid  retroflexion  without  care- 
ful exclusion  of  ectopic  pregnancy. 

Pyosalpinx. — Double  pyosalpinx  or  collections  of  pus  in  both 
Fallopian  tubes  may  closely  simulate  a  tubal  pregnancy.  With 
the  pyosalpinx  we  generally  have  regular  menstruation  with  per- 
haps menorrhagia  or  occasional  metrorrhagia.  Occasionally,  how- 
ever, there  is  complete  amenorrhoea.  The  preceding  condition 
of  health  may  help  to  clear  up  matters.  A  history  of  purulent 
vaginal  discharge  followed  by  pelvic  pains  would  furnish  evidence 
pointing  to  pus  tubes. 

Myoma. — Sometimes  a  tubal  pregnancy  simulates  very  closely 
a  uterine  myoma.  The  tubal  pregnancy  is  more  apt  to  cause  pain, 
especially  when  there  is  a  peritubal  hsematocele.  A  myoma  in 
or  projecting  from  the  side  of  the  uterus  is  seldom  painful  even 
when  handled. 

Twisted  pedicle  tumors,  whether  of  the  tube  or  ovary,  produce 
serious  symptoms.  When  the  pedicle  becomes  so  far  twisted  as 
to  obstruct  the  circulation  the  symptoms  closely  resemble  those 
caused  by  a  rupture  of  a  tubal  pregnancy.  In  such  cases,  how- 
ever, the  twisted  pedicle  tumors  do  not  appear  to  be  so  closely 
connected  with  the  uterus  as  the  tubal  pregnancy. 

In  giving  these  points  as  to  differential  diagnosis  I  have  closely 


GROWING,  FULL  TERM,  DEAD  TREGNANCY  329 

followed  Taylor.  Although  good  in  a  way,  they  are  necessarily 
incomplete.  No  one  can  give  directions  by  which  we  can  with 
certainty  reach  a  diagnosis  in  all  cases.  Pregnancy  in  a  rudimen- 
tary horn  of  a  bilobed  uterus  occasionally  occurs.  Rupture  is  not 
delayed  beyond  five  months. 


GROWING  PREGNANCY,  FULL  TERM  PREGNANCY, 
DEAD  PREGNANCY 

Tubo -Abdominal  Variety. — The  symptoms  and  treatment  of 
other  forms  are  the  same  as  in  tubal  pregnancy.  While  preg- 
nancy within  the  abdominal  cavity  is  going  on  after  tubal  rupture, 
and  especially  after  the  fourth  month,  we  have  chiefly  noticeable 
the  ordinary  signs  of  uterine  pregnancy.  Careful  examination, 
however,  will  always  show  certain  differences  between  the  normal 
and  the  misplaced  pregnancy.  In  abdominal  pregnancy  the  foetus 
and  placenta  are  probably  "  rather  lateral  or  zigzag  in  position." 
The  sac  of  pregnancy  is  not,  as  a  rule,  distended  by  liquor  amnii. 
The  foetal  movements  cause  serious  pain.  The  foetus  may  be 
mapped  out  very  easily,  the  limbs  may  be  sometimes  isolated 
and  grasped.  The  foetal  heart  is  sometimes  peculiarly  accessible 
and  clearly  detected.  In  placing  the  hands  over  the  abdomen 
there  is  not  found  any  expanding  and  contracting  of  muscular 
fibers.  On  bimanual  examination  the  cervix  is  generally  found  to 
be  soft  and  patulous,  the  uterus  is  generally  displaced  toward  one 
side  of  the  pelvis,  only  slightly  enlarged  and  obviously  distinct 
from  the  child.  In  tubo-ligamentary  pregnancy,  however,  the 
uterus  is  more  enlarged  and  not  obviously  distinct  from  the  child. 

It  sometimes  happens  that  in  a  normal  intra-uterine  pregnancy 
we  may  find  symptoms  very  similar  to  those  described  when  the 
walls  of  the  uterus  are  unusually  thin.  An  extraordinary  thinness 
of  the  uterine  walls  is  sometimes  found  with  or  without  hydro- 
salpinx. I  think  it  is  Culling  worth  who  reports  a  case  where 
abdominal  pregnancy  was  supposed  to  exist,  the  real  condition, 
however,  of  intra-uterine  pregnancy,  was  only  discovered  after 
abdominal  section. 

Growing  Tubo-Ligamentary  Pregnancy. — In  a  large  proportion 
of  cases  of  intraligamentous  pregnancy  the  posterior  layer  of  the 
broad  ligament  is  the  one  chiefly  displaced  by  the  growing  ovum — 
that  is,  the  pregnancy  is  really  retroperitoneal  not  subperitoneal. 


330     EXTEA-UTEEIKE    OE    ECTOPIC    PEEGNANCY 

There  is,  in  such  cases,  a  hardness  and  fixity  of  the  tumor  which  is 
not  found  in  the  abdominal  pregnancy.  The  uterus  in  such  cases 
is  considerably  enlarged  and  closely  attached  to  the  sac  of  the 
pregnancy.  It  is  generally  somewhat  difficult  to  make  a  diag- 
nosis. It  is  especially  difficult  to  make  a  differential  diagnosis 
from  intra-uterine  pregnancy,  pregnancy  in  one  side  of  a  double 
uterus  and  pregnancy  in  one  horn  of  a  bicornuate  uterus. 

Full  Term  and  Dead  Pregnancy ;  False  Labor. — When  an  ectopic 
pregnancy  reaches  full  term  certain  symptoms  appear  which  gen- 
erally give  the  patient  the  impression  that  she  is  in  labor.  As 
delivery  can  not  occur  without  artificial  assistance  the  term  ' '  false 
labor  "  is  applied  to  the  phenomena  which  appear  at  this  time. 
The  patient  has  pains  which  are  not  due,  however,  to  uterine  con- 
tractions, but  to  the  movements  of  the  foetus.  There  is  generally 
some  vaginal  discharge  and  sometimes  expulsion  of  decidual  mem- 
branes. The  pains  usually  last  some  days  and  are  sometimes  quite 
distressing.  They  then  cease  suddenly,  as  a  rule,  and  the  move- 
ments of  the  child,  now  dead,  are  no  longer  felt. 

This  is  sometimes  called  ' '  missed  labor."  After  this  the  breasts 
temporarily  enlarge  and  secrete  milk.  After  a  short  time  all  the 
symptoms  of  pregnancy,  except  the  enlargement  of  the  abdomen, 
disappear. 

Results.  1.  The  hquor  amnii  may  be  absorbed  and  the  soft 
parts  may  become  adipocere. 

2.  The  foetus  may  remain  unchanged  for  many  years. 

3.  The  foetus  may  shrink,  calcareous  matters  be  deposited, 
producing  a  lithopsedion. 

4.  Suppuration  in  sac  may  occur,  causing  septicaemia. 

Treatment  During  the  First  Four  Months  of  Pregnancy. — For- 
tunately there  is  but  little  difference  of  opinion  as  to  treatment. 
Obstetricians  generally  agree  that  the  proper  treatment  is  oper- 
ative. In  all  cases  of  unruptured  ectopic  pregnancy  and  all  intra- 
peritoneal ruptures  the  operation  of  abdominal  section  should  be 
immediately  performed.  It  is  true  that  occasionally  a  patient 
having  a  tubal  mole  with  a  peritubal  hsematocele,  or  a  ruptured 
tubal  pregnancy,  recovers  without  operation.  The  proportion  of 
such  recoveries,  however,  is  very  small,  about  5  per  cent.,  accord- 
ing to  Taylor.  We  ought  certainly  to  take  no  chances  where  the 
odds  are  so  overwhelmingly  against  the  patient. 

It  requires  considerable  courage  to  operate  as  Ross  did  in  the 


GROWIXO,  FTLL  TER^r,  DEAD  PREGNANCY  331 


case  I  have  reported.     Algernon  Temple  showed  siniilar  courage 
when  he  went  to  Hamilton,  about  four  years  ago,  and  operated  on 

Mrs.  ,  a  daughter  of  a  prominent  physician  of  that  city. 

Although  the  patient  was  apparently  in  extremis  she  made  a  good 
recovery,  much  to  the  surprise  of  Temple  himself  and  those  present. 
Cullingworth  operated  once  under  apparently  hopeless  circum- 
stances after  the  patient  had  been  for  some  hours  "  pale,  cold,  rest- 
less and  pulseless.  The  operation  lasted  half  an  hour.  No  pulse 
could  be  felt  during  the 
whole  of  that  time  or  for 
three  hours  afterward." 
Recovery. 

A  few  years  ago  efforts 
were  made  to  destroy  the 
embrj^o  in  the  misplaced 
pregnancy  by  evacuating 
the  liciuor  amnii,  by  injec- 
tion of  fluids  into  the  sac, 
and  by  the  use  of  electric- 
ity. Such  methods  have 
fallen  into  disrepute  and 
are  now  practically  obso- 
lete. 

Mistakes  are  made  in 
diagnosis.  There  may  be, 
for  instance,  a  history 
indicating  ectopic  preg- 
nancy, and  a  mass  beside 
the  uterus  easily  felt  by  a 
vaginal  examination.     In 

such  a  case  the  operation  is  indicated  whether  this  mass  be  an 
ectopic  gestation  sac,  a  pyosalpinx,  or  a  hydrosalpinx. 

In  urgent  cases — that  is,  when  rupture  has  occurred — the  ac- 
coucheur should  immediately  send  for  assistants  and  also  make 
preparations  for  operation.  Elevate  the  foot  of  the  bed  or  the  hips 
of  the  patient,  administer  an  enema  of  saline  solution,  using  one 
pint,  inject  a  quart  of  normal  saline  solution  under  the  breasts. 
Give  hypodermics  of  strychnia,  ^^  o^  ^  grain  every  hour  for  five 
or  six  doses.  Some  give  larger  doses  of  both  but  I  prefer  to  be 
careful  when  there  is  so  little  reserve  force  to  draw  on.    Apply  hot- 


FiG.  124. — Ectopic  Gestation. 

Lithopsedion  retained  in  abdomen  seven  years. 
(W.  H.  Taylor,  Tor.  Univ.  Museum.) 


332     EXTRA-UTEEINE    OR   ECTOPIC    PREGKANCY 

water  bags  or  bottles  to  the  sides  of  the  body  and  extremities.  Get 
ready  clean  towels,  bed  linen,  etc.,  douche  bag,  clean  basins,  sterile 
water,  hot  water,  antiseptics,  iodoform  gauze,  etc.  A  description 
of  the  operation  is  given  on  page  563. 

Subperitoneal  Rupture. — While  it  is  generally  admitted  that 
an  operation  is  indicated  in  all  cases  of  unruptured  ectopic  preg- 
nancy, and  also  in  all  cases  of  intraperitoneal  rupture,  there  is 
some  difference  of  opinion  as  to  the  treatment  of  subperitoneal 
rupture.  In  this  form  the  symptoms  are  not  so  acute  as  in  the 
intraperitoneal  variety,  the  haemorrhage  being  restricted  by  the 
surrounding  structures.  In  many  cases  the  embryo  speedily  dies, 
while  it  and  the  blood  thrown  out  are  absorbed  in  a  comparatively 
short  time.  Some  prefer  to  treat  this  class  of  cases  on  the  modified 
expectant  plan — i.  e.,  keeping  the  patient  quiet,  watching  her  care- 
fully, and  interfering  if  serious  symptoms  arise.  I  prefer  in  such 
cases  non-interference  unless  the  symptoms  become  serious  either 
from  excessive  hsemorrhage  or  sepsis. 

Others  think  that  the  immediate  removal  of  the  gestation  sac 
is  the  proper  treatment,  especially  in  view  of  the  possibility  or 
probability  of  sepsis,  and  on  account  of  the  severe  pain  generally 
present.  If,  when  the  patient  is  first  seen,  considerable  time  has 
elapsed  since  the  rupture,  she  may  be  practically  convalescent. 
Under  such  circumstances  an  operation  is  needless.  In  other  cases 
she  may  be  suffering  from  complications  which  should  receive  suit- 
able treatment. 


CHAPTER  XV 

HEMORRHAGE  BEFORE,  DURING  AND  AFTER  LABOR 

The  various  forms  of  hffimorrhage  occurring  before,  during  and 
after  labor  produce  some  of  the  most  acute  emergencies  which  are 
encountered  in  obstetrical  practise.  A  very  careful  study  of  this 
subject  is  important,  not  only  on  account  of  the  serious  results 
which  frequently  follow,  but  also  because,  even  in  the  worst  cases, 
prompt  and  correct  treatment  will  generally  prevent  a  fatal  issue. 

HAEMORRHAGE  BEFORE  LABOR 

The  haemorrhages  which  occur  before  or  during  labor  are  gen- 
erally due  to  one  of  two  causes. 

1.  Partial  or  complete  separation  of  a  normally  situated  pla- 
centa (accidental  haemorrhage) . 

2.  Abnormal  situation  of  the  placenta  (placenta  prsevia). 

In  exceptional  cases  the  haemorrhages  are  due  to:  1.  Cancer, 
most  frequently  of  the  cervix.     2.  Rupture  of  a  varix. 

We  thus  have  four  varieties,  two  ordinary  and  two  exceptional : 
1.  Accidental  haemorrhage.  2.  Haemorrhage  from  placenta  prse- 
via. 3.  Haemorrhage  from  cancer  of  the  cervix.  4.  Haemorrhage 
from  a  ruptured  varix  of  the  vulva  or  vagina. 

ACCIDENTAL   HEMORRHAGE 

This  is  haemorrhage  caused  by  premature  detachment  of  the 
normally  inserted  placenta,  or  "ablatio  placentae."  The  separa- 
tion may  be  complete  or  (generally)  partial.  The  supposed  causes 
are:  predisposing;  endometritis,  diseased  placenta;  exciting;  an 
accident;  unusually  strong  contraction  of  the  uterus;  short  cord; 
great  distention  of  the  uterus  as  from  plural  pregnancy. 

Varieties. — The  varieties  of  accidental  haemorrhage  are:  1.  Ex- 
ternal accidental  haemorrhage.  2.  Concealed  accidental  haemor- 
rhage. 

In  the  external  form  the  blood  finds  its  way  between  the  mem- 

333 


334     HEMORRHAGE  BEFORE  AND  AFTER  LABOR 


branes  and  the  decidua  and  escapes  from  the  vagina.  The  symp- 
toms are :  escape  of  blood  from  the  vagina,  escape  of  serum  from 
the  vagina,  the  usual  symptoms  of  haemorrhage. 

Diagnosis  of  External  Accidental  Haemorrhage. — When  the 
blood  appears  externally  it  is  generally  due  to  either  accidental 
haemorrhage  or  to  haemorrhage  from  placenta  praevia.  If  it  is 
found  by  abdominal  palpation  that  the  head  presents  and  is  fixed 
in  the  brim  it  is  almost  certainly  not  placenta  praevia.  If  it  is 
found  by  vaginal  examination  that  the  presenting  part  can  be  felt 
as  well  as  usual  and  no  placenta  can  be  felt  in  the  lower  uterine  seg- 
ment it  is  not  placenta  praevia. 

Concealed  Form. — In  the  concealed  form  the  blood  fails  to  pass 
externally  and  is  retained  between  the  ovum  and  the  uterine  wall, 
or  passes  through  the  ruptured  membranes  into  the  interior  of  the 
ovum.  The  symptoms  are:  irregularity  and  feebleness  of  the 
uterine  contractions,  the  fundus  only  contracting;  the  syncope  and 

collapse  are  more  se- 
vere and  persistent 
than  ordinary  faint- 
ing ;  the  uterus  is  very 
sensitive ;  the  pains 
are  of  a  tearing  char- 
acter; the  uterus  is 
increased  in  size 
(sometimes) ;  palpa- 
tion of  the  uterus  is 
difficult  or  impossible. 
Differential  Diag- 
nosis of  Concealed 
Accidental  Haemor- 
rhage.— It  is  most 
likely  to  be  mistaken 
for  rupture  of  the 
uterus  or  rupture  of 
a  sac  in  ectopic  preg- 
nancy. The  symp- 
toms occur  more  early  than  in  ruptured  uterus,  and  are  not,  as 
a  rule,  preceded  by  such  strong  pains.  In  ruptured  uterus  the 
child  often  recedes  into  the  abdominal  cavity.  In  ectopic  gesta- 
tion the  sac  generally  ruptures  early  in  pregnancy. 


Fig.  125. — Accidental  Hemorrhage. 


B, 


A,  Placenta  mostly  attached,  partly  separated 

site  of  separation ;   C,  blood  passing  down  be 
tween  the  membranes  and  the  uterine  wall. 


ILEMORRHAGE    BEFORE    LABOR 


335 


Prognosis  of  Concealed  Form. — The  prof^nosLs  is  grave,  the  mor- 
tality of  mothers  being  about  50  per  cent.,  and  that  of  the  children 
being  still  greater. 

The  pain  and  rapid  collapse  in  cases  of  concealed  accidental 
haemorrhage  are  remarkable.  This  collapse  is  supposed  by  some 
to  be  due  entirely  to  the 
loss  of  blood.  It  is 
likely,  however,  that 
the  collapse  is  due  as 
much  or  more  to  the 
extreme  pain  than  to 
the  outpour  of  blood. 
There  happens  to  be 
quite  a  difference  of 
opinion  on  this  point 
and  I  think  much  mis- 
conception. Take,  for 
instance,  the  opinions 
of  certain  British  au- 
thors. Jellett  tells  us 
that  "collapse,  falling 
temperature,  weak  and 
rapid  pulse,  severe  abdominal  pain,  anaemic  appearance — all  occur 
in  proportion  to  the  amount  of  blood  which  the  patient  is  losing." 

Galabin,  in  discussing  this  subject,  says  in  one  place  that  "  the 
patient  may  die  from  haemorrhage  undelivered";  but  in  another 
place  he  refers  to  the  additional  "element  of  shock  through  the 
distention  of  the  uterus,"  and  then  goes  on  to  say  that  "  the  very 
fact  of  the  uterus  allowing  such  distention  proves  that  its  walls  are 
feeble  or  not  prone  to  contract." 

Herman  attaches  much  importance  in  such  cases  to  the  "sud- 
den stretching  "  of  the  uterus,  the  acute  pain  which  results  there- 
from and  the  extreme  prostration  which  is  thus  produced.  My 
own  views  as  to  the  predominant  importance  of  the  amount  of 
blood  lost  have  been  changed  in  recent  years,  chiefly  through  a 
careful  study  of  the  following  cases. 

Case  I.  Mrs.  A.    Ill  para.    About  three  weeks  before  full  term  slipped 

while  climbing  a  fence.     Some  abdominal  pain  and  a  feeling  of  faintness 

for  a  short  time.     Next  forenoon  suddenly  seized  with  a  severe  abdominal 

pain.     Physician  and  nurse  summoned.     The  former  found  no  sign  of 

23 


Fig.  126. — Accidental  Hemorrhage  Concealed. 

A,  Blood  retained  between  the  placenta  and  the 
uterine  wall;  B,  placenta  separated  at  center 
with  adherent  margins. 


336     H^MOERHAGE  BEFOEE  AND  AFTER  LABOR 

labor,  did  not  appreciate  the  significance  of  the  extreme  pain,  and  left  the 
house.  Thus  much  valuable  time  was  lost.  The  patient  grew  rapidly- 
worse.  Late  in  the  afternoon  was  delivered  of  a  dead  child  and  a  large 
quantity  of  blood  followed.     Mother  died  a  few  minutes  later. 

Case  II.  Dr.  W.  P.  Caven's  patient.  Mrs.  B.,  aged  thirty-three. 
IV  para.  Labor  pains  commenced  at  midnight,  strong  at  8  a.  m.  Seen  by 
Caven  at  9.30.  Then  in  a  state  of  collapse.  Dr.  McKenzie,  Dr.  Ross 
and  I  were  summoned.  Patient  anaesthetized  and  delivered  {accouche- 
ment force)  at  11.30.  Considerable  blood,  mostly  in  clots,  expressed. 
Patient  died  one  hour  after  delivery.  Dr.  McKenzie  expressed  his  sur- 
prise that  the  quantity  of  blood  poured  out  (about  one  quart)  produced 
such  serious  results.  I  myself  had  seen  more  blood  lost  in  cases  of  post- 
partum hsemorrhages  without  fatal  results,  and  suspected  some  form  of 
shock,  apart  from  collapse  due  to  mere  loss  of  blood,  was  in  a  measure 
responsible  for  the  death  of  the  patient. 

Case  III.  June,  1902.  Mrs.  C,  II  para,  aged  twenty-nine.  When 
about  seven  months  advanced  in  pregnancy  was  suddenly  seized  with 
severe  abdominal  pain,  while  driving,  after  a  jar  caused  by  the  carriage 
wheel  passing  over  a  stone.  Went  home  (only  a  short  distance)  as  soon 
as  possible.  Went  up-stairs  intending  to  go  to  bed,  collapsed  while  un- 
dressing. Saw  her  in  about  twenty  minutes  and  found  her  cold  and  weak, 
pale,  with  rapid  pulse,  and  suffering  intensely  from  "tearing"  pains  over 
the  abdomen,  especially  near  the  right  iliac  region.  Gave  her  two  doses 
of  nepenthe  within  a  few  minutes.  Second  dose  gave  some  relief  but  she 
was  still  suffering  greatly  at  the  end  of  an  hour  and  I  then  gave  her  a 
hypodermic  of  morphine.  This  gave  more  relief  and  in  about  three  hours 
after  the  collapse  she  was  nearly  free  from  pain.  Remained  in  bed  three 
days  feeling  fairly  well.  Motions  of  child  felt  up  to  time  of  collapse  but 
not  after.  Four  days  after  the  accident  labor  commenced.  Dead  babe 
born  in  fourteen  hours,  followed  by  some  clots.  The  placenta  showed 
evidence  of  being  about  half  detached  for  some  days.  In  this  case  the 
shock  and  collapse  were  evidently  due  to  the  tearing  pains  caused  by  the 
sudden  stretching  of  the  uterus,  and  not  at  aU  to  the  loss  of  blood,  which 
did  not  amount  to  more  than  one  pint. 

Case  IV.  Patient  seen  with  Dr.  Allen  Baines  at  11  a.  m.  Apparently 
in  labor,  great  pain  over  uterus,  some  shock,  no  expulsive  uterine  con- 
tractions, only  slight  dilatation  of  the  os.  Chloral  given.  Normal  labor 
pains  commenced  about  noon  and  child  born  dead  about  5  p.  m.  A  large 
clot  followed  expulsion  of  the  placenta.  Although  I  am  sure  from  what 
Dr.  Baines  told  me  that  this  clot  was  much  larger  than  that  found  in 
Case  III,  the  symptoms  of  pain  and  shock  were  not  so  severe. 

Albert  Macdonald  reported  two  cases  to  the  Toronto  Medical 
Society  in  1892.  In  both  the  patients  during  the  greater  part  of 
pregnancy  had  continuous  severe  pain  over  that  portion  of  the 


H^MOREHAGE    BEFORE    LABOR  337 

uterus  which  he  found  to  correspond  with  the  placental  site.  Both 
patients  recovered. 

It  is  strange  that  the  sudden  escape  of  a  pint  of  blood  from  torn 
vessels  beneath  the  placenta  or  membranes  should  produce  such  a 
profound  effect  on  the  whole  system  as  in  my  case,  III.  The  preg- 
nant uterus,  with  its  great  nerve  and  muscle  developments,  be- 
comes a  very  powerful  but  exceedingly  sensitive  organ.  We  have 
found  that  under  certain  abnormal  or  unusual  conditions,  such  as 
premature  escape  of  the  liquor  amnii  or  prolonged  labor  from  any 
cause,  serious  results  follow,  such  as  tetanic  contraction,  frequently 
accompanied  by  agonizing  pain.  In  case  of  accidental  concealed 
ha?morrhage  the  sudden  stretching  of  the  uterus  by  the  invading 
blood  produces  a  great  effect  on  some  of  the  uterine  nerve  plexuses 
and  thence  immediately  on  the  whole  body  somewhat  similar  to 
that  produced  by  a  sharp  stroke  of  a  cricket  ball  in  the  neighbor- 
hood of  the  solar  plexus.  In  certain  of  the  so-called  fulminating 
cases  the  symptoms  are  much  like  those  produced  by  hemorrhage 
into  the  substance  of  the  pancreas,  which,  although  insignificant  in 
amount,  sometimes  causes  death  in  an  hour  or  two,  as  happened 
to  a  patient  of  Dr.  Allen  Baines  recently.  Thus  we  have  shock 
rather  than  collapse,  or  frequently  both — shock  from  the  sudden 
stretching  together  with  collapse  from  loss  of  blood,  the  former 
predominating  in  certain  cases.  Many  who  have  accepted  the 
opinion  of  Galabin  think  that  the  distention  of  the  uterus  under 
such  circumstances  proves  that  its  walls  are  enfeebled  by  some 
previous  disease,  such  as  advanced  metritis.  I  know  nothing 
about  such  weakness  of  the  uterine  wall.  In  the  cases  I  have 
met  I  thought  the  uterine  wall  had  its  normal  tone  and  supposed 
the  resisting  power  in  it  was  the  chief  factor  in  the  symptoms 
produced. 

I  have  not  referred  to  other  cases  where  I  have  found  small 
blood  clots  of  two  to  four  ounces  beneath  the  placenta,  but  I  be- 
lieve these  somewhat  insignificant-looking  masses  often  produce 
very  severe  pains  before  the  onset  of  labor,  and  that  such  pains  are 
continuous  in  character  and  frequently  last  for  several  hours,  the 
true  cause  being  seldom  suspected.  One  should  always  think  of 
this  condition  when  he  meets  patients  suffering  from  sharp  ab- 
dominal pain,  colic-like  in  character,  at  or  toward  the  end  of  gesta- 
tion. 


338     H^MOERHAGE  BEFOEE  AND  AFTER  LABOR 


TREATMENT    FOR    EXTERNAL    HEMORRHAGE 

When  the  haemorrhage  is  only  sHght,  rest  and  quiet,  with  the 
administration  of  opium  and  viburnum  prunifoHum  as  recom- 
mended for  the  treatment  of  threatened  abortion,  may  prevent 
any  further  serious  symptoms.  This  is  apt  to  be  the  case  when 
only  a  small  portion  of  the  placenta  is  detached.  Patients  under 
such  circumstances  ought  of  course  to  be  very  carefully  watched. 

Active  Interference. — When  interference  becomes  necessary  we 
have  to  consider  two  conditions.  In  the  one  case  there  is  no 
sign  of  even  the  commencement  of  labor,  while  the  haemorrhage 
is  copious.  In  the  other  case  the  patient  is  in  labor  and  the  parts 
are  wholly  or  partially  dilated.' 

The  following  rules  will  cover  the  two  varieties : 

1.  Plug  the  vagina  if  the  os  is  undilated  and  the  membranes 
are  unruptured. 

2.  Puncture  the  membranes  and  deliver  as  soon  as  possible  if 
the  patient  is  in  labor  and  the  os  is  wholly  or  partially  dilated. 

The  Dublin  Method. — The  following  is  a  brief  description  of 
the  Dublin  method,  which  is  only  to  be  employed  when  severe 
haemorrhage  occurs  before  labor  with  os  undilated  and  ovum  in- 
tact— i.  e.,  when  the  membranes  are  unruptured.  Plug  the  vagina 
tightly,  using  antiseptic  methods.  This  will  do  three  things : 
1.  Check  the  haemorrhage.  2.  Bring  on  labor.  3.  Give  time  to 
rally  from  shock  if  present. 

Leave  the  plug  in  until  strong  labor  pains  ensue,  usually  in 
from  three  to  four  hours. 

In  some  cases  the  onset  of  labor  may  be  slower  and  then  plug 
must  be  removed  after  twelve  hours  for  fear  of  decomposition. 
(I  am  using  mostly  Jellett's  words,  but  utero-vaginal  tamponade 
is  discussed  and  described  in  another  chapter  and  the  opinion  is 
expressed  that  an  antiseptic  plug  may  be  left  in  the  vagina  or 
even  the  uterus  for  a  much  longer  time.)  If  haemorrhage  comes 
on  again  another  plug  must  be  introduced,  but  this  is  usually  un- 
necessary. I  approve  of  this  method,  although  some  authors  tell 
us  that  such  treatment  is  wrong.  Galabin  tells  us  "  the  membranes 
should  be  punctured  as  soon  as  possible."  ''  Plugging  the  vagina 
is  considered  inadmissible  in  cases  of  accidental  haemorrhage  be- 
cause concealed  haemorrhage  might  be  going  on  behind  the  plug." 
Dakin  tells  us  that  after  the  introduction  of  a  sponge  tent  into  the 


HAEMORRHAGE  BEFORE  LABOR       339 

cervical  canal  when  "  the  uterus  begins  to  distend  and  the  woman 
to  show  signs  of  fresh  loss  of  blood  it  will  be  obvious  that  the  case 
is  one  of  accidental  hirmorrhage,  which  the  tent  has  converted  into 
the  concealed  variety."  Fothergill,  speaking  for  Edinburgh,  tells 
us  that  "  plugging  the  vagina  must  be  carefully  avoided  in  acci- 
dental hiemorrhage.  The  site  of  bleeding  is  too  high  up  to  be  affect- 
ed by  this  kind  of  pressure  and  its  only  result  is  to  convert  external 
into  concealed  hajmorrhage. ' ' 

These  are  high  authorities,  representing  the  soundest  and  most 
conservative  obstetrical  elements  of  London  and  Edinburgh,  and 
their  statements  deserve  careful  consideration.  I  think,  however, 
that  Dublin  in  this  instance  is  right,  and  that  the  results  of  the 
tampon  treatment  in  the  Rotunda  during  the  last  eleven  years; 
under  the  masterships  of  Smyly  and  Purefoy,  prove  that  such  is 
the  case. 

Rupture  of  the  Membranes. — Consider  the  alternative  proced- 
ure as  recommended  by  so  many — puncture  of  the  membranes. 
Rupture  of  the  membranes  before  the  onset  of  labor  is  dangerous 
in  the  extreme.  By  the  decrease  of  the  intra-uterine  pressure  the 
haemorrhage  is  increased  up  to  the  time  of  the  onset  of  the  uterine 
contractions  of  labor.  In  a  large  proportion  of  cases  the  puncture 
of  the  membranes  increases  the  haemorrhage  and  causes  such 
serious  symptoms  that  accouchement  force  or  removal  of  the  uterus 
becomes  necessary.  So  far  as  I  know,  Albert  Macdonald  was  the 
first  in  this  province  to  enter  a  decided  protest  against  rupture 
of  the  membranes  for  accidental  haemorrhage  before  the  onset 
of  labor. 

Another  feature  of  such  cases  is  important.  Frequently  the 
accoucheur  will  be  unable  to  decide  whether  the  haemorrhage  is 
accidental  or  unavoidable  because  he  can  not  pass  the  finger  through 
the  undilated  os.  If,  however,  he  believes  that  the  tampon  is  suit- 
able for  any  form  of  uterine  haemorrhage  before  rupture  of  the 
membranes  a  grave  cause  of  perplexity  is  removed. 

Rapid  Delivery  When  Os  is  Fairly  Well  Dilated  and  the  Mem- 
branes Are  Unruptured, — After  labor  has  commenced,  especially  if 
the  OS  is  fairly  well  dilated,  it  is  better  to  complete  delivery  as  soon 
as  possible.  This  is  not  difficult  as  a  rule  after  labor  has  com- 
menced. Let  an  assistant  anaesthetize  the  patient  to  the  surgical 
degree,  and  then  dilate  thoroughly  the  vagina.  Generally  when 
the  whole  hand  is  carefully  introduced  into  the  vagina  the  cervix 


340     H^MOEEHAGE  BEFOEE  AND  AFTEE  LABOE 

has  become  dilatable.  The  dilatation  of  the  vagina  generally 
stimulates  uterine  contractions  if  labor  has  begun,  and  in  accord- 
ance with  the  laws  of  polarity  such  contractions  tend  to  produce 
dilatability  of  the  os.  One  should  be  careful  in  dilating  the  os  be- 
cause the  cervix  is  sometimes  very  rigid  and  easily  torn,  although 
such  danger  is  not  nearly  so  great  as  in  cases  of  placenta  prsevia. 
After  dilatation  of  the  soft  parts,  the  proper  procedure  is  to  turn 
at  once  if  the  head  presents  and  extract.  Occasionally,  when  the 
head  is  engaged  in  the  brim  or  has  entered  the  pelvis  it  is  better 
to  deliver  with  the  forceps. 

TREATMENT    FOR    CONCEALED    HEMORRHAGE 

I  think  that  the  serious  symptoms  caused  by  this  accident 
should  be  placed  in  the  same  category  with  symptoms  produced 
by  other  varieties  of  nerve  storms  which  occur  during  pregnancy 
or  labor,  such  as  those  which  cause  eclampsia  or  tetanic  contrac- 
tion, and  should  receive  similar  treatment. 

Treat  first  the  shock  by  the  administration  of  morphine, 
chloroform,  stimulants,  and  the  application  of  heat  externally. 
I  have  found  nepenthe  or  morphine  by  the  mouth  too  slow  in 
action.  Administer  ^  grain  of  morphine  hypodermically — follow 
with  ^  grain  every  half  hour  for  two  or  three  doses  if  required, 
also  chloroform  if  pains  are  not  relieved  by  the  morphine.  If 
symptoms  are  very  severe  and  there  is  a  nurse  or  physician  as 
assistant  let  one  at  once  commence  to  administer  chloroform  while 
the  other  gives  the  hypodermic  injection  of  morphine.  Minutes 
— even  seconds — are  valuable.  Severe  pain  sometimes  kills  in  a 
very  short  time.  If  alone  send  for  a  consultant,  but  don't  wait 
for  his  arrival.  Give  morphine  and  chloroform  at  once.  With 
reference  to  Case  II,  I  have  often  thought  that  if  Dr.  Caven  had 
seen  his  patient  one-half  hour  sooner  he  could  have  saved  her  life. 
If  patient  has  not  reached  full  term  and  is  not  in  labor,  further  im- 
mediate interference  in  many  cases  is  unnecessary  as  in  Case  III. 

If  labor  has  commenced  always  deliver  as  soon  as  possible. 
Dilate  the  soft  parts  by  first  introducing  the  hand  into  the  vagina 
and  then  the  fingers  into  the  cervix.  Bring  down  a  leg  or  apply 
forceps  and  deliver  as  before  directed.  If  labor  has  not  commenced 
but  symptoms  remain  very  severe,  notwithstanding  the  adminis- 
tration of  morphine  and  chloroform,  empty  the  uterus  as  soon  as 
possible. 


HEMORRHAGE    BEFORE    LABOR 


341 


PLACENTA   PRiEVIA 

When  the  placenta  is  situated  in  the  lower  segment  of  the 
uterus — i.  e.,  close  to  or  over  the  internal  os — it  is  said  to  be 
jyrcevia.  Its  frequency  is  about  1  in  700  cases.  In  this  unusual 
position  the  placenta  is  thinner  and  the  placental  area  larger 
than  normal,  and  placentae  succenturiatffi  are  more  common. 

Two  varieties  are  given — i.e.,  complete  and  incomplete;  but 
these  do  not  cover  the  ground  as  to  the  position  of  the  placenta. 
The  important  point  is  that 
the  placenta  is  situated  near 
or  over  the  internal  os.  It 
may  thus  be  marginal  or  lat- 
eral, the  edge  being  within  a 
short  distance  from  or  just 
reaching  the  os,  or  it  may 
cross  over  the  os  and  simply 
touch  the  edge  beyond  the  os, 
or  it  may  cross  further  until 
the  center  of  the  placenta  cor- 
responds nearly  or  exactly  to 
the  internal  os.  The  source 
of  the  blood  is  generally  ad- 
mitted to  be  the  torn  vessels 
and  sinuses  in  the  uterine  wall. 
Symptoms. — The  most  or- 
dinary symptom  is  the  haem- 
orrhage ("unavoidable"), 
which  may  come  on  at  any 
time,  especially  in  the  later 
months  of  pregnancy.  It  may 
commence  after  unusual  ex- 
ertion or  an  accident,  but  it 
not  infrequently  begins  while  the  patient  is  quiet  in  bed.  The 
patient  generally  goes  through  the  first  half  of  pregnancy  without 
abnormal  symptoms.  The  haemorrhage  is  most  apt  to  appear  first 
during  the  seventh  or  eighth  month.  It  begins  earlier  where  there 
is  central  implantation  (usually  from  the  twenty-eighth  to  the 
thirty-fourth  week)  and  later  when  there  is  lateral  implantation 
(usually   after   the   thirty-sixth    week).      Early   haemorrhage    is 


Fig.  127. — Placenta  Previa. 

A,  placenta  in  lower  segment  covering  the 
OS  and  touching  the  edge  beyond  the  os  ; 
B,  OS  uteri. 


342     H^MOEEHAGE  BEFOEE  AND  AFTEE  LABOE 


generally  more  slight  than  that  occurring  later.     When  the  first 
haemorrhage  commences  during  labor  it  is  generally  copious. 

There  are  in  severe  cases  the  ordinary  constitutional  symptoms 
of  haemorrhage:  pallor,  cold  skin,  irregular  respiration,  thready 
pulse,  air  hunger,  thirst,  jactitation,  tinnitus  aurium,  nausea,  dim- 
ness of  vision,  and  syncope. 

Some  (including  Spiegelberg)  think  that  the  haemorrhage  is 
always  checked  to  some  extent  during  the  acme  of  a  pain.     Others 

think  the  haemorrhage  is  increased 
during  pains.  There  is  really  no 
fixed  rule  in  either  direction. 

Diagnosis.  —  Vaginal  stetho- 
scopy  as  an  aid  to  diagnosis  was 
proposed  several  years  ago  and 
tried  by  some.  I  think,  however, 
such  procedure  is  now  practically 
obsolete. 

The  diagnosis  is  sometimes 
difficult  or  impossible  before  dil- 
atation of  the  OS.  Some  think 
they  can  occasionally  discover  the 
position  of  the  placenta  by  ab- 
dominal palpation  when  it  is  situ- 
ated on  the  anterior  uterine  wall  by 
noticing  that  the  foetal  parts  are 
felt  less  distinctly  over  the  pla- 
cental area.  The  only  certain  proof 
of  the  condition  is  obtained  by 
vaginal  examination,  passing  one 
or  two  fingers  through  the  cervical 
canal,  and  feeling  either  the  edge  of  the  placenta  near  the  inter- 
nal OS,  or  the  placental  tissue  if  it  is  situated  over  the  internal  os. 
Premature  Labor. — Premature  labor  is  the  rule  in  placenta 
praevia.  Labor  usually  follows  haemorrhage.  The  pains  are  apt 
to  be  comparatively  weak  on  account  of  the  situation  of  the  pla- 
centa, which  disturbs  the  polarity  of  the  uterus  and  prevents  the 
proper  action  of  the  presenting  part  on  the  cervix,  and  because 
the  patient  is  often  exhausted  by  haemorrhage.  Transverse  pres- 
entations and  imperfect  flexion  of  the  head  are  common. 

As  labor  advances  and  the  advancing  membranes  gradually 


Fig.  128. — Placenta  Previa. 

A,  complete  placenta  praevia,  center 
of  placenta  over  os ;  B,  os  uteri. 


HiEMORRHAGE    BEFORE    LABOR  343 

produce  dilatation,  the  i)lacenta  when  situated  over  the  os  becomes 
partially  detached.  As  the  prcevia  is  seldom  exactly  central  com- 
plete detacliment  takes  i)lace  first  on  one  side  of  th(!  internal  os — 
i.  e.,  on  the  side  where  the  smaller  ])ortion  of  the  placenta  is  situated. 
Thus  the  central  prcevia  becomes  converted  into  the  marginal  or 
lateral.  When  the  placenta  is  originally  marginal  or  becomes  so 
by  Nature's  work  or  by  artificial  interference,  the  head  or  breech 
may  press  against  the  placenta  if  the  uterine  contractions  are 
strong  or  fairly  strong  and  stop  the  haemorrhage.  At  the  same 
time  the  separation  or  detachment  of  a  portion  of  the  placenta 
allows  retraction  of  the  uterus  to  occur  and  this  tends  to  stop  the 
haemorrhage.  Occasionally  the  central  pncvia  is  not  converted 
into  a  lateral  or  marginal  one.  Instead,  the  placenta  is  wholly 
detached  and  driven  down  before  the  child.  In  such  cases  the 
patients  generally  do  well,  but  the  children  are  nearly  always  still- 
born. 

Prognosis. — Formerly  the  maternal  mortality  was  from  25  to 
40  per  cent.,  but  by  improved  methods  of  treatment,  including 
aseptic  and  antiseptic  precautions,  it  has  been  reduced  to  5  to 
10  per  cent.  The  mortality  as  to  the  children  is  perhaps  greater 
under  the  new  methods  than  it  was  under  the  old,  although  Her- 
man's statement  that  the  mortality  of  the  children  has  increased 
from  60  to  90  per  cent,  under  our  new  methods  is  somewhat  sur- 
prising, and  is  not  correct  with  regard  to  Canada  and  the  United 
States. 

TREATMENT   OF     PLACENTA    PREVIA 

Perplexities  of  Physician. — So  much  depends  on  the  symptoms, 
especially  as  to  the  quantity  of  blood  lost,  and  there  is  such  a  dif- 
ference of  opinion  on  certain  points,  that  no  definite  rules  which 
will  be  acceptable  to  all  can  be  given.  I  shall  suggest  rather  con- 
cisely the  following  rules: 

When  the  haemorrhage  commences  before  the  child  is  viable  be 
guided  by  the  character  of  the  haemorrhage. 

If  the  haemorrhage  is  slight  carry  out  the  expectant  plan  of 
treatment — i.  e.,  keep  patient  quiet  in  bed,  keep  bowels  fairly  open, 
give  opiates  and  viburnum  as  required. 

This  advice  is  condemned  by  many  able  and  conscientious  ob- 
stetricians who  say  that  the  mother  is  never  safe  under  such  cir- 
cumstances, as  a  fatal  recurrence  of  haemorrhage  may  occur  at  any 


344     H^MOEEHAGE  BEFOEE  AND  AFTEE  LABOE 

time.  This  is  true,  but  ^t  the  same  time  the  fact  remains  that  a 
fatal  haemorrhage  before  the  child  is  viable  is  rare.  One  should, 
however,  always  recognize  the  element  of  danger  under  such  cir- 
cumstances and  watch  the  patient  with  the  greatest  of  care.  If 
the  patient  is  five  to  ten  miles  away  from  her  physician  the  peril 
to  her  is  still  greater. 

Let  us  consider  the  matter  from  the  other  side — i.  e.,  in  the  in- 
terest of  the  unborn  babe.  Some  of  us  think  that  a  six  months' 
foetus  has  certain  rights  which  can  not  be  legally  or  morally  dis- 
regarded. The  mother  may  have  certain  views  about  the  life  of 
the  "expected  "  little  one.  The  courts  may  require  the  physician 
to  ''show  cause"  for  the  induction  of  an  abortion.  The  church 
may  ask  why  he  has  deliberately  destroyed  an  unborn  babe.  The 
perplexities  of  such  a  situation  are  very  serious.  One  should  study 
each  case  carefully  in  all  its  aspects  and  get  the  assistance  and 
advice  of  a  consultant. 

If,  on  the  other  hand,  one  finds  the  haemorrhage  so  copious  as  to 
endanger  the  life  of  the  mother  he  should  endeavor  to  control  the 
haemorrhage  and  empty  the  uterus  as  soon  as  possible.  Even  if 
he  could  keep  the  mother  alive  for  a  few  weeks  the  chances  of  the 
birth  of  a  living  child  would  be  so  infinitesimal  as  to  be  scarcely 
worthy  of  consideration.  If  haemorrhage  commences  about  the 
time  the  child  has  become  viable  the  situation  is  preeminently 
perplexing.  In  such  a  case  Herman's  statement  that  "  in  placenta 
prsevia  the  life  of  the  mother  and  that  of  the  child  are  antag- 
onistic" is  nearly,  if  not  altogether,  correct. 

The  safe  procedure,  under  such  circumstances,  is  to  induce  pre- 
mature labor  in  the  interest  of  the  mother.  Still,  in  my  own  prac- 
tise I  do  not  always  adhere  rigidly  to  this  rule.  If  haemorrhage  is 
only  slight  and  I  have  the  impression  that  the  child  is  only  barely 
viable  I  sometimes  carry  out  the  expectant  plan — I  mean  the  care- 
fully watchful  expectant  plan. 

I  think  that  in  such  a  case  one  should  take  counsel,  not  only 
with  a  consulting  accoucheur  but  also  with  the  husband  and  wife, 
and  that  he  should  at  the  same  time  respect  the  scruples  of  the 
church,  which  upholds  God's  law—''  Thou  shalt  do  no  murder." 
If  one  decides  to  wait  for  a  time  the  patient  should  be  placed  in  a 
hospital  if  possible,  or  a  competent  nurse  should  be  secured  to 
watch  her  carefully  if  she  remains  in  her  own  house. 

If  haemorrhage  commences  toward  the  end  of  eighth  or  in  the 


HiEMOERHAGE  BEFORE  LABOR       345 

ninth  month  of  pregnancy  one  should  inrhice  premature  labor  if 
labor  has  not  already  commenced.  In  a  large  proportion  of  these 
cases  labor  commences  soon  after  a  hemorrhage.  If  this  happens 
while  one  is  waiting  in  doubt  as  to  his  correct  course  all  perplexities 
as  to  choice  will  be  removed. 

Methods  of  Procedure. — Before  referring  in  detail  to  certain 
methods  of  procedure  it  may  be  well  to  consider  some  facts  as  to 
the  condition  of  the  lower  uterine  segment  and  cervix.  Placenta 
praevia  causes  a  congestion  and  softening  of  the  lower  segment, 
which  makes  it  easily  torn.  In  a  certain  minority  of  cases  it  ap- 
pears to  be  like  wet  blotting  paper. 

The  condition  of  the  cervix  varies  greatly.  In  the  majority  of 
cases  it  is  c^uite  soft  and  dilatable.  In  about  12  per  cent,  of  cases, 
however,  according  to  Miiller,  it  is  abnormally  rigid.  In  any  case 
copious  haemorrhage  nearly  always  causes  some  dilatation  of  the 
cervix,  but  manual  or  instrumental  stretching,  although  easily 
accomplished,  will  often  cause  rupture  before  it  produces  further 
dilatation,  and  such  rupture  readily  extends  into  the  softened  lower 
uterine  segment. 

When  interference  is  deemed  necessary,  our  methods  wdll  de- 
pend on  the  conditions  present. 

1.  When  there  is  serious  haemorrhage,  with  only  slight  dilata- 
tion of  OS  and  no  sign  of  labor,  the  proper  procedure  is  to  induce 
labor.  Krause's  method,  by  the  introduction  of  one  or  two  flex- 
ible bougies,  is  not  suitable.  Vaginal  tamponade,  as  recommended 
for  accidental  haemorrhage  while  the  ovum  is  intact,  is  the  correct 
procedure  because  here  again  it  not  only  brings  on  labor  pains  but 
it  also  controls  the  haemorrhage.  It  is  advisable  then  to  apply 
tightly  an  abdominal  bandage.  After  the  removal  of  the  plug  in 
from  ten  to  thirty  hours  there  will  probably  be  considerable  soften- 
ing of  the  cervix  and  increased  dilatation  of  the  os. 

2.  When  there  is  serious  haemorrhage,  with  the  os  dilated  suf- 
ficiently to  admit  two  fingers,  the  following  is  recommended : 

Braxton  Hicks'  Method. — Turn  by  the  combined  method  and 
bring  down  a  leg  in  the  case  of  ordinary  head  presentation ;  then 
leave  to  Nature.  Such  is  a  description  of  the  method  in  a  few 
words.  Two  gross  errors  frequently  creep  into  the  practise  of  this 
method.  Many  practitioners  do  not  wait  long  enough  to  allow 
Nature  to  sufficiently  dilate  the  os.  Some  wait  only  for  fifteen  to 
thirty  minutes,  but  the  only  safe  plan  is  to  wait  for  hours  if  neces- 


346     H^^MOERHAGE  BEFOEE  AND  AFTER  LABOR 

sary  until  regular  uterine  contractions  have  partially  expelled  the 
child.  A  few  months  ago  an  excellent  and  careful  practitioner  of 
Toronto  was  conducting  a  case.  The  mother  was  especially  anx- 
ious to  have  a  living  child,  as  he  knew.  The  foot  was  protruding 
from  the  vulva.  The  pressure  of  the  breech  was  effectually  pre- 
venting haemorrhage.  Everything  seemed  favorable,  but  delay 
might  mean  danger  to  the  child.  Consequently,  gentle  traction 
was  used  and  the  child  born  alive.  The  result  to  the  mother  was 
rupture  of  the  uterus  and  death  in  a  few  hours. 

Dr.  Bascom,  of  Parkdale,  recently  placed  a  patient  with  sus- 
pected placenta  prsevia  under  my  care  in  the  Burnside.  She  had 
two  haemorrhages  before  and  one  after  admission.  Pregnancy  was 
advanced  nearly  eight  months.  August  13th,  4  p.  m.,  an  examina- 
tion was  made  during  the  third  haemorrhage,  the  patient  being 
fully  anaesthetized.  There  was  a  central  placenta  praevia  and  the 
cervix  was  sufficiently  dilated  to  admit  two  fingers  easily.  I  sep- 
arated the  placenta  around  the  internal  os,  but  could  not  reach  its 
edge  in  any  direction.  I  then  pushed  two  fingers  through  the  pla- 
centa, turned  by  the  combined  method  and  brought  down  a  foot. 
Slight  traction  was  made  on  the  foot  until  the  child's  body  acted 
as  an  efficient  plug.  The  patient  was  then  carefully  watched,  but 
there  was  no  further  interference.  Ordinary  labor  pains  came  on 
about  2  A.  M.,  and  child  and  placenta  were  delivered  at  4  a.  m. — i.  e., 
twelve  hours  after  version.  No  haemorrhage  during  the  twelve 
hours  while  the  foot  was  outside  the  vulva  with  a  clean  bandage 
fastened  with  a  clove  hitch  around  the  ankle,  and  an  antiseptic 
pad  over  the  foot  and  vulva.  Not  more  than  an  ounce  or  two  of 
blood  lost  during  delivery  of  placenta. 

The  second  error  is  to  neglect  the  child  and  allow  it  to  be  still- 
born. Wait  patiently  until  the  cervix  is  dilated.  Watch  care- 
fully while  the  child  is  being  expelled,  and  as  soon  as  it  is  born  as 
far  as  the  umbilicus  interfere  promptly  and  aid  further  delivery  by 
the  methods  described  for  ordinary  breech  labors.  If  these 
methods  are  carried  out  the  infant  mortality  will  not  be  90 
per  cent. 

In  cases  of  complete  placenta  praevia  one  may  not  be  able  to 
pass  the  two  fingers  past  the  edge  of  the  placenta  on  either  side  of 
the  internal  os.  In  such  a  contingency  pass  the  finger  round  the 
whole  circumference  within  the  os  and  separate  the  placenta  as  far 
as  possible,  by  Barnes'  method.     If  this  does  not  improve  matters 


H^MOERHAGE    BEFORE    LABOR 


347 


push  two  fingers  through  the  placenta,  or  a  long  curved  artery- 
forceps,  or  some  suitable  blunt  instrument  first,  and  then  dilate 
the  opening  thus  made  with  the  fingers  as  recommended  by  Gar- 
rigues.  Then  pass  the  fingers  up  and  bring  down  a  leg,  use  traction 
until  breech,  by  its  pressure,  stops  haemorrhage,  and  then  wait  and 
at  the  proper  time  helj)  as  before  described. 

The  Use  of  Champetier  de  Ribes'  Bag.— Instead  of  Braxton 
Hicks'  method,  many  use  De  Ribes'  unyielding  bag  or  Voorhees' 


Fig.  129. — Cancer  of  Cervix  with  Pregnancy. 
Half  showing  membranes,  early  stage  of  placental  formation  but  no  embryo. 


dilating  bags.  The  directions  are:  Rupture  the  membranes  and 
introduce  the  bag  if  possible  through  the  rupture  and  fill  it  with 
water.  Pull  on  the  bag  gently  but  continuously.  A  small  weight 
may  be  attached  to  it  by  a  cord  passing  over  a  pulley  at  the  foot 
of  the  bed.  Haemorrhage  is  thus  controlled  and  the  cervix  gradu- 
ally dilated.  When  the  distended  bag  comes  away  apply  forceps 
and  extract;  or  turn  and  bring  down  a  leg  as  before  described. 


348   HiEMOEEHAGE  BEFOEB  AND  AFTEE  LABOE 


This  is  thought  by  some  to  give  the  child  a  better  chance  than 
Hicks'  method.  In  some  of  the  New  York  Maternities  this  is  the 
method  commonly  employed  in  such  cases.  It  is  more  difficult 
than  the  Hicks'  method  and  more  frequently  followed  by  sepsis. 

Other  Methods. — 
In  incomplete — i.  e., 
marginal  or  lateral — 
prsevia,  when  labor  is 
fairly  advanced  and 
the  cervix  is  dilated  or 
dilatable,  rupture  of 
the  membranes  and 
the  application  of  a 
tight  abdominal  bind- 
er is  usually  sufficient. 
Very  frequently  there 
is  imperfect  flexion  of 
the  child's  head.  In 
two  cases  I  have  been 
able  with  the  internal 
fingers  to  flex  the  head 
completely  and  then 
with  the  external  hand 
to  push  the  head  into 
the  brim,  after  which 
the  haemorrhage  was 
controlled.  In  one  of 
these  cases  Nature 
completed  delivery  in 
a  ■  few  hours ;  in  the 
other  I  delivered  with 
forceps.  If  unable  to 
make  the  head  act  as  a  tampon,  and  if  haemorrhage  continues,  turn 
and  bring  down  a  leg  and  then  leave  to  Nature  for  a  time  as  before 
described. 


Fig.  130. — Cancer  of  Cervix  with  Pregnancy. 
Half  containing  the  embryo.      (Tor.  Univ.  Museum.) 


HEMORRHAGE  FROM   CANCER   OF  THE   CERVIX 


This  has  been  mistaken  for  haemorrhage  from  placenta  praevia. 
Treatment. — Perform  abdominal  or  vaginal  hysterectomy. 


POST-PARTUM    HAEMORRHAGE  349 

HAEMORRHAGE    FROM   A   RUPTURED    VARIX    OF   THE   VAGINA 

OR   VULVA 

Treatment. — Apply  a  ligature  if  bleeding  vessel  can  be  found, 
or  apply  pressure  with  vaginal  plug  of  iodoform  gauze,  or  apply 
pressure  with  pad  applied  to  vulva  and  held  in  position  with  a 
T-bandage. 

POST-PARTUM  HAEMORRHAGE 

There  is  always  some  haemorrhage  after  the  delivery  of  the 
child,  although  the  amount  of  blood  lost  is  sometimes  very  small. 
When  the  amount  is  large  (a  pint  or  more)  we  use  the  term  post- 
partum haemorrhage. 

Varieties. — There  are  two  varieties  as  to  the  source  of  the 
haemorrhage :  a.  From  the  placental  site.  b.  From  a  laceration  of 
the  cervix,  vagina,  vulva  or  perinseum. 

1.  As  to  Source. — In  the  great  majority  of  cases  the  bleeding 
takes  place  at  the  placental  site.  On  this  account  a  serious  hajmor- 
rhage  arising  from  a  laceration  of  the  cervix  or  some  part  below  the 
cervix  is  frequently  misunderstood.  Some  of  the  Rotunda  men 
speak  of  these  two  varieties  as  atonic  and  traumatic.  The  word 
atonic  is  not  suitable  because  we  may  have  excessive  haemorrhage 
when  there  is  tonic  contraction  and  also  when  there  is  irregular 
contraction  of  the  uterus.  The  word  traumatic  is  quite  suitable, 
but  it  is  more  common  to  apply  this  term  to  crushing  or  bruising, 
and  to  speak  of  laceration  as  the  particular  kind  of  traumatism 
which  causes  haemorrhage.  In  many  cases,  if  not  in  all,  the  haemor- 
rhage from  a  laceration  has  a  more  marked  constitutional  effect 
than  the  loss  of  a  similar  amount  from  the  placental  site.  There 
seems  here  again  to  be  an  element  of  shock  from  the  laceration 
added  to  the  collapse  caused  by  the  haemorrhage. 

2.  As  to  Time. — There  are  also  two  varieties  as  to  time:  a. 
Primary — Within  six  hours  after  labor,  h.  Secondary — Occurring 
more  than  six  hours  after  labor. 

PRIMARY  POST-PARTUM   HEMORRHAGE 

Causes  of  Primary  Post-Partum  Haemorrhage. — 1.  Inertia  of 
the  uterus  with  imperfect  retraction.  2.  Neoplasms — myoma, 
etc.  3.  Irregular  uterine  contractions  (hour  glass) .  4.  Retained 
portions  of  placenta  with  perhaps  adhesions.     5.  Natural  tendency 


350     H^MOREHAGE  BEFORE  AND  AFTER  LABOR 

to  bleed  (bleeders  or  fiooders).  6.  Placenta  prsevia  because  lower 
segment  of  the  uterus  has  feeble  contractile  power. 

This  list  of  causes,  while  fairly  correct,  is  not  altogether  satis- 
factory. It  is  generally  supposed  and  taught  that  the  common 
cause  of  post-partum  haemorrhage  from  the  placental  site  is  inertia 
of  the  uterus  and  especially  what  is  called  secondary  uterine  iner- 
tia. And  yet  we  frequently  have  associated  with  this  form  of 
inertia  tetanic  contraction  of  the  uterus,  which,  while  sometimes 
favoring  haemorrhage,  seldom  causes  copious  bleeding;  and,  more 
important  still,  we  often  have  a  degree  of  retraction  which  will 
effectually  prevent  excessive  uterine  haemorrhage. 

While  neoplasms  and  haemophilia  are  causes  of  the  haemorrhage 
it  is  probable  that  fibro-myomata  do  not  cause  excessive  haemor- 
rhage in  the  majority  of  cases. 

Symptoms. — The  most  important  and  the  most  common  symp- 
tom is  the  external  haemorrhage  which  may  take  place  before  or 
after  the  expulsion  of  the  placenta.  Along  with  this  haemorrhage, 
or  even  preceding  it,  is  found  the  rapid  pulse.  At  the  same  time 
the  hard  uterine  ball  can  not  be  detected  by  the  hand  over  the  ab- 
dominal wall.  There  are  present  also  the  usual  symptoms  of  severe 
haemorrhage. 

In  a  certain  proportion  of  cases,  however,  there  is  no  external 
haemorrhage,  or,  as  the  old-fashioned  midwife  expressed  it,  no 
"  flooding."  My  first  midwifery  case  in  private  practise  was  one 
of  this  sort.  My  partner,  the  late  Dr.  A.  N.  Bethune,  had  charge 
of  a  patient  in  labor.  The  labor  was  normal  and  about  half  an 
hour  after  the  expulsion  of  the  placenta  Dr.  Bethune  left  the  house. 
Serious  symptoms  appeared  after  his  departure  and  I  was  sum- 
moned. The  patient  was  pale,  cold,  faint,  unconscious,  and  almost 
pulseless  at  the  wrist.  There  was  surely  haemorrhage.  Is  there 
any  flowing  f  No — the  nurse  said.  I  placed  my  hand  over  ab- 
domen— could  feel  no  uterus — nothing  but  a  big  soft  boggy  mass. 
What  had  I  here?  Concealed  haemorrhage.  Dr.  Uzziel  Ogden, 
my  teacher  of  midwifery,  had  described  this  condition  and  told  us 
how  to  treat  it.  Although  much  alarmed  I  promptly  introduced 
my  hand  into  the  uterus,  gently  forced  it  through  an  hour-glass 
contraction  and  removed  nearly  two  quarts  of  blood  mostly  in 
clots,  and  in  other  respects  carried  out  the  ordinary  treatment 
for  collapse  from  haemorrhage.  The  patient  made  a  slow  but 
good  recovery. 


POST-PARTUM    HEMORRHAGE  351 

TREATMENT    OF    ORDINARY     PRIMARY    POST-PARTUM    HEMORRHAGE 
FROM    THE     PLACENTAL    SITE 

Prophylactic  Treatment. — Many  years  ago  we  learned  from 
the  DuhUn  School  that  post-partum  haemorrhage  can  generally  be 
prevented  by  a  certain  routine  line  of  treatment  which  should  be 
carried  out  in  every  case.  Occasionally  we  find  a  scientific  theorist 
who  explains  the  laws  of  contraction  and  retraction  and  shows 
that  these  two  forces  will  prevent  haemorrhage  after  the  delivery 
of  the  child  if  we  do  not  interfere.  I  believe,  however,  that  the 
proper  plan  is  to  "  follow  down"  the  uterus  during  the  expulsion 
of  the  child  and  "  watch  carefully  "  the  uterus  during  the  expres- 
sion of  the  placenta  and  for  at  least  half  an  hour  after  as  directed 
in  the  chapter  on  physiological  obstetrics.  One  should  avoid  vio- 
lent kneading  or  strong  pressure  over  the  uterus,  which  causes 
great  pain  without  accomplishing  any  good.  One  may  either 
keep  the  fundus  in  the  hollow  of  the  palm  or  rub  the  uterus  gently 
with  one  finger-tip.  If  the  uterus  enlarges  to  any  extent  one  may 
exert  a  little  force  and  endeavor  to  use  pressure  so  as  to  squeeze 
out  clots  which  have  formed,  and  with  the  pressure  use  a  certain 
amount  of  friction. 

Actual  Treatment. — Fortunately,  one  can  give  definite  rules 
for  treatment  which  are  generally  accepted. 

Give  at  once  one  dram  of  fluid  extract  of  ergot  or  inject  some 
preparation  of  ergot  or  ergotine  hypodermically.  Always  empty 
the  uterus  as  soon  as  possible.  Try  first  to  squeeze  out  the  clots 
by  external  friction  and  pressure.  Porter  Mathew  places  the  tips 
of  the  fingers  on  the  fundus  and  then  rapidly  rotates  the  hand  with 
a  vibratory  action.  This  often  causes  contraction  speedily  after 
ordinary  kneading  has  failed.  If  unable  to  accomplish  this  in  a 
short  time  (say  one  or  two  minutes — a  long  time  when  a  woman  is 
bleeding  to  death),  cleanse  one  hand  in  the  lysol  solution  and  then 
introduce  it  into  the  uterine  cavity.  Clear  out  all  clots,  rub  the 
interior  of  the  uterus  with  the  finger-tips  while  the  palm  of  the  ex- 
ternal hand  is  pressing  on  the  uterus.  While  thus  engaged  let  the 
nurse  lower  the  patient's  head  by  removing  pillows;  raise  the  foot 
of  the  bed,  and  apply  heat  to  the  surface.  After  doing  this  let  her 
prepare  a  pint  of  hot  saline  solution  for  a  high  enema. 

In  the  great  majority  of  cases  this  will  be  sufficient  to  promote 

contraction  and  stop  the  haemorrhage.     If  the  haemorrhage  still 
24 


352      H^MOEEHAGE  BEFOEE  AND  AFTEE  LABOE 

continues  give  a  hot  intra-uterine  douche  about  120°  F.,  or  as  hot 
as  the  fingers  (not  arm)  can  be  kept  in  without  discomfort,  using 
two  quarts  of  the  sterile  water  or  boric  solution.  This  will  cause 
considerable  burning  pain  in  the  skin  near  the  vulva,  which  may  be 
to  a  large  extent  prevented  by  smearing  the  external  genitals  with 
vasehne.  If  hot  water  is  not  quickly  available,  take  a  cupful  of 
vinegar,  soak  some  clean  cotton  in  it,  carry  this  into  the  interior  of 
the  uterus  in  the  hand  and  squeeze  it. 

If  haemorrhage  continues  after  the  douche  or  after  the  use  of 
vinegar  consider  bimanual  compression  and  plugging  the  uterine 
cavity.  The  bimanual  compression  may  be  tried  if  the  abdominal 
walls  are  not  rigid,  the  bladder  not  distended,  and  there  is  no  tetanic 
contraction  of  the  uterus.  A  good  form  of  bimanual  compression 
is  that  described  by  Herman :  Bend  the  fingers  of  the  left  hand  on 
the  palm  and  introduce  the  fist  into  the  vagina  and  push  it  against 
the  bod}''  and  cervix  of  the  uterus,  while  counter  pressure  is  made 
by  the  right  hand  which  grasps  the  uterus  externally.  Schroder 
introduces  two  fingers  instead  of  the  fist  into  the  vagina.  Some- 
times the  aorta  may  be  felt  and  compressed  against  the  vertebral 
column  a  little  above  the  promontory.  Such  pressure  shuts  off 
half  the  blood  supply  to  the  uterus,  and,  it  is  said,  is  sometimes 
beneficial.  I  have  not  had  good  results  from  any  of  the  methods  of 
compression  but  it  requires  only  a  short  time  to  make  a  trial,  and 
I  therefore  refer  to  it  here  before  mentioning  tamponade  of  the 
uterine  cavity. 

Method  of  Fritsch. — Professor  Fritsch  has  recently  recom- 
mended a  compression  method  which  it  is  claimed  speedily  con- 
trols the  haemorrhage. 

The  accumulation  of  blood  in  the  uterine  cavity  is  expressed, 
and  the  hands  are  placed  between  the  recti,  which  are  usually 
easily  pushed  aside,  so  as  to  reach  the  back  of  the  uterus,  which  is 
raised  as  high  as  possible,  forcibly  anteflexed  and  compressed 
against  the  superior  and  posterior  surfaces  of  the  pubes.  The 
internal  os  then  lies  exactly  above  the  pubic  portion  of  the  ilio- 
pectineal  fine.  The  abdominal  walls  immediately  after  delivery 
are  easily  forced  behind  the  uterus  as  deeply  as  the  pelvic  brim. 
The  resulting  funnel-shaped  pouch  of  skin  and  muscle  is  firmly 
plugged  with  folded  towels,  linen,  or  if  sufficient  is  available  with 
large  pads  of  cotton-wool,  until  the  uterus  is  immovably  fixed 
against  the  anterior  abdominal  wall  and  the  pubes.     A  roller-band- 


POST-PARTUM    H/EMOREHAGE  353 

age  is  applied  over  the  padding,  which  is  thus  forced  behind  the 
uterus  toward  the  pelvic  inlet.     The  body  of  the  uterus  then  lies 
above  and  in  front  of  the  symphysis  pubis. 
The  method  has  the  following  advantages : 

1.  By  compression  of  the  abdominal  cavity  blood  is  retained 
in  the  upper  half  of  the  body  even  more  effectually  than  by  direct 
compression  of  the  abdominal  aorta  and  bandaging  the  legs. 

2.  Hiemorrhage  is  impossible  as  the  uterine  walls  are  so  pressed 
together  that  the  uterine  cavity  is  obliterated. 

3.  Haemostasis  is  immediate.  If  the  uterine  cavity  is  plugged 
large  quantities  of  blood  escape  during  the  operation,  and  are 
absorbed  by  the  tampon  itself.  Professor  Fritsch  has  seen  cases 
in  which,  after  completion  of  plugging,  the  woman  was  found 
to  be  dead. 

4.  No  time  is  lost  in  disinfecting  the  hands,  as  no  internal  ma- 
nipulations are  required. 

5.  The  pad  once  in  place,  no  further  disturbance  of  the  patient 
is  necessary,  and  there  are  no  uterine  plugs  to  be  removed. 

Plugging. — If  after  a  trial  of  all  these  methods  the  haemorrhage 
continues  there  remains  only  one  procedure  which  in  my  opinion 
is  worthy  of  consideration.  Plug  the  uterine  cavity  with  iodoform 
gauze  as  first  recommended  by  Duhrssen  (for  technique  see  page 
507).  If  afraid  of  the  penetrability  of  the  gauze  use  salicylic  cot- 
ton-wool plugs.  Duhrssen  prefers  the  gauze  for  Ihe  post-partum 
haemorrhage  and  wool  plugs  when  there  is  haemorrhage  from  the 
lower  uterine  segment  (placenta  praevia)  and  cervical  lacerations. 
If  there  is  no  contraction  of  uterus  after  utero-vaginal  tamponade 
on  account  of  atony  of  the  uterus  compress  the  fundus  uteri  against 
the  tampon  by  the  hand  externally  over  abdomen.  If  haemorrhage 
comes  on  in  an  hour  or  two  after  tamponade  it  is  probably  due  to 
contraction  of  the  uterus  squeezing  blood  out  of  the  gauze.  In 
such  a  case  remove  the  gauze  at  once. 

Many  years  ago  Robert  Barnes  advised  the  injection  into  the 
uterus  of  a  solution  of  the  perchloride  of  iron  diluted  with  w^ater 
(1  in  4)  in  -cases  of  serious  post-partum  haemorrhage.  This  is  now 
generally  considered  dangerous  and,  at  the  same  time,  less  effective 
than  the  tamponade.  The  late  Dr.  Carson  used  the  perchloride  in 
the  case  of  a  "  bleeder."  The  uterine  haemorrhage  stopped,  but 
she  soon  commenced  to  bleed  from  the  nose.  The  haemorrhage 
from  the  nose  continued  so  long  that  it  caused  quite  as  much 


354     H^MOEEHAGE  BEFOEE  AND  AFTEE  LABOE 

alarm  as  did  that  from  the  uterus.  I  attended  this  patient  in  her 
next  labor,  Dr.  Carson  having  died  during  the  interval.  Knowing 
her  history  I  was  especially  careful  as  to  prophylaxis  and  prompt 
in  carrying  out  the  different  methods  which  I  have  recommended. 
(I  have  never  injected  an  iron  preparation  for  uterine  haemorrhage.) 
After  introducing  the  gauze  into  the  uterus  and  vagina  the  bleed- 
ing did  not  stop  at  once.  I  then  introduced  two  fingers  into  the 
vagina  and  pressed  against  the  tampon,  using  counter  pressure  ex- 
ternally over  the  fundus  with  the  other  hand.  This  pressure  was 
kept  up  for  nearly  three  hours,  with  occasional  intervals  for  rest 
and  observation. 

In  another  case,  in  the  Burnside,  in  which  there  was  consider- 
able post-partum  haemorrhage  after  a  craniotomy  (dead  child), 
we  introduced  the  gauze  tampon.  Contrary  to  my  expectations  the 
patient  died,  but  I  thought  her  death  was  caused  partly  by  shock 
from  chloroform  and  operation,  and  not  simply  from  haemorrhage. 

It  is  sometimes  difficult  or  impossible  to  decide  whether  the 
bleeding  is  taking  place  from  the  interior  of  the  uterus  or  from  a 
cervical  or  vaginal  tear,  or  it  may  be  from  both  the  interior  of  the 
uterus  and  a  cervical  or  vaginal  tear.  In  any  such  case  utero- 
vaginal tamponade  is  suitable  treatment. 

Haemorrhage  in  which  the  blood  does  not  come  from  the  in- 
terior of  the  uterus  is  due  to  some  form  of  traumatism.  Severe 
traumatic  haemorrhage  is  most  commonly  caused  by  laceration  of 
cervix  or  laceration  in  the  neighborhood  of  the  clitoris.  In  any 
such  accident  ligature  or  suture  is  the  most  efficient  method  of 
stopping  the  bleeding,  as  a  rule.  Frequently,  however,  the  or- 
dinary tampon  may  be  more  easily  introduced  or  pressure  more 
easily  applied.  A  ligature  or  a  double  ligature  is  often  necessary 
for  a  laceration  in  the  region  of  the  clitoris. 

TREATMENT    OF    COLLAPSE    FROM    POST-PARTUM    HEMORRHAGE 

Opium. — The  most  important  thing  in  the  treatment  of  col- 
lapse after  haemorrhage  from  any  cause  is  the  administration  of 
opium  in  full  doses.  As  Mathew  tells  us — the  whole  aspect  of  the 
case  is  altered  in  a  few  minutes;  the  distressed  countenance  be- 
comes calm,  hurried  respiration  becomes  quiet,  a  thready,  running 
pulse  becomes  steady,  the  awful  sense  of  impending  calamity 
passes  away.  Give  half  a  dram  of  tincture  of  opium  by  the 
mouth,  or  a  quarter  of  a  grain  of  morphine  by  hypodermic  injec- 


POST-PARTUM    HEMORRHAGE  355 

tion  and  twenty  minims  of  tincture  of  opium  by  enema.  Mathcw 
thinks  that  the  opium  has  a  better  effect  when  given  by  the  mouth. 
I  speak  definitely  about  the  full  doses  of  opium  in  such  cases  be- 
cause I  have  found  that  some  practitioners  are  afraid  to  adminis- 
ter opiates  during  collapse  from  post-partum  haBmorrhage.  At  the 
same  time  lower  the  head,  elevate  the  foot  of  the  bed,  cover  with 
warm  blankets,  apply  hot  bottles  to  feet,  legs,  thighs  and  body, 
especially  near  heart,  and  hot  cloths  to  head  and  neck,  and  give 
ether  and  digitalin  or  strychnine  by  hypodermic  injection. 

The  next  most  important  thing  is  the  injection  of  normal  saline 
solution  to  replace  the  fluid  lost.  Pass  the  tube  of  a  fountain 
syringe  well  up  into  the  rectum,  or  use  a  tube  and  funnel  and  inject 
slowly  a  pint  of  sahne  at  100°  F.,  with  one  or  two  ounces  of  whiskey. 
This  may  be  repeated  in  an  hour.  The  enema  thus  carefully  ad- 
ministered (or  the  sahne  simply  ''allowed  to  run  slowly  into  the 
rectum  ")  generally  produces  a  good  result  in  a  short  time.  Many 
prefer  the  subcutaneous  injection  of  the  saline  solution.  This 
answers  well  and  is  generally  done  in  the  Burnside ;  but  in  private 
practise  the  enema  is  safer,  easier  to  administer,  and  as  a  rule  quite 
as  efficient. 

Give  small  quantities  of  liquids  by  the  mouth  every  few  min- 
utes, as  soon  as  the  stomach  will  tolerate  them,  but  be  careful  not 
to  induce  the  patient  to  take  enough  to  cause  retching  or  vomiting. 

Intravenous  saline  injection  is  favored  by  many  surgeons  and 
gynaecologists  and  some  obstetricians.  The  dangers  connected 
with  the  procedure  are  so  many  and  so  great  that  the  average  prac- 
titioner is  scarcely  justified  in  performing  so  serious  an  operation. 

The  so-called  auto-transfusion — i.  e.,  the  application  of  a  tight 
bandage  to  the  four  extremities — is  not  safe;  but  partial  auto- 
transfusion — i.  e.,  the  bandage  on  leg  and  thigh  on  one  side  and 
forearm  and  arm  of  the  other  side — is  probably  quite  safe  and 
occasionally  serviceable.  The  transfusion  of  blood  from  vein  to 
vein^  or  from  artery  to  artery,  is  both  dangerous  and  ineffective, 
and  therefore  not  worth  considering. 

SECONDARY   POST-PARTUM   HEMORRHAGE 
Causes. — Many  causes  and  methods  of  treatment  have  been 
aescribed,  but  I  think  there  is  only  one  cause  and  one  line  of  treat- 
ment.    The  cause  is  the  retention  of  a  portion  or  portions  of  the 
secundines  or  an  old  clot,  or  clots. 


356     H^MOEEHAGE  BEFOEE  AND  AFTEE  LABOE 

This  form  of  haemorrhage,  sometimes  called  remote  or  delayed 
puerperal  haemorrhage,  is  probably  more  common  than  is  generally 
supposed.  It  frequently  happens  that  profuse  haemorrhage  com- 
mences quite  suddenly  after  the  ordinary  lochial  discharges  have 
ceased  for  some  time  to  be  sanguineous. 

In  one  patient  under  my  care  after  an  easy  normal  labor, 
the  lochia  after  the  fourth  day  grew  lighter  in  color,  being  quite 
pale  by  seventh  day,  involution  satisfactory.  On  tenth  day, 
without  any  apparent  cause,  a  sudden  haemorrhage  commenced 
sufficiently  copious  to  be  rather  alarming.  I  introduced  the 
hand  into  the  vagina  and  without  much  trouble  passed  two  fin- 
gers into  uterus  and  removed  clots.  Could  feel  no  solid  sub- 
stance for  a  time,  but  after  a  careful  exploration  found  a  small 
mass  which  I  scratched  away  with  some  difficulty.  This  was 
found  to  be  a  piece  of  placenta,  free  from  offensive  odor,  about 
the  size  of  a  small  bean.  No  haemorrhage  after  this.  Patient 
made  a  good  recovery. 

In  another  patient  a  serious  haemorrhage  commenced  on  ninth 
day  after  labor.  The  fingers  removed  a  good-sized  piece  of  the 
membranes  with  a  small  piece  of  placenta  attached  to  one  corner. 
No  further  haemorrhage.  In  neither  of  these  cases  was  there  any 
serious  difficulty  in  introducing  hand  into  vagina  and  two  fingers 
into  uterus  without  an  anaesthetic.  I  prefer  anaesthesia,  however, 
in  such  cases. 

In  another  patient,  under  the  care  of  Dr.  A.,  a  rather  severe 
haemorrhage  occurred  on  the  tenth  day  after  delivery.  Patient 
kept  very  quiet,  ergot,  ergotine,  sulphuric  acid,  quinine,  etc.,  ad- 
ministered; slight  improvement,  but  haemorrhage  never  stopped 
altogether.  On  the  twenty-fourth  day  after  delivery  a  haemor- 
rhage, more  severe  than  that  of  the  tenth  day,  occurred.  After 
a  consultation  a  more  vigorous  line  of  treatment  was  adopted, 
the  cervical  canal  was  dilated  and  two  small  pieces  of  placenta 
were  removed.  No  further  haemorrhage.  In  this  case  the  fingers 
should  have  been  introduced  into  the  uterus  on  the  tenth  instead 
of  the  twenty-fourth  day  after  delivery. 

Dangers. — We  may  look  upon  the  dangers  arising  from  reten- 
sion  of  uterine  secundines  and  clots  in  three  aspects : 

1.  Immediate  Danger  from  Hcemorrhage.  That  this  is  very 
grave  is  proved  by  the  fact  that  deaths  from  this  kind  of 
haemorrhage  occasionally  occur  as  reported  by  McClintock  Collins 


POST-PARTUM    H/EMORBHAGE  357 

and  others.  These  sad  results  may  be  rare,  but  leaving  such  ex- 
treme cases  out  of  the  question  it  is  impossible  to  estimate  the 
injury  which  a  woman  during  and  after  the  puerperium  may 
sustain  from  such  hicmorrhage.  It  is  the  time  when  it  is  most 
important  for  her  to  .conserve  all  her  vital  forces  for  the  sake  of 
herself,  and  also  for  her  child  who  lives  through  her.  Who  can 
tell  how  often  a  haemorrhage  of  this  sort  has  been  sufficient  to 
turn  the  balance  in  a  constitution  which  before  that  accident  had 
been  able  to  battle  successfully  against  some  serious  disease  such 
as  tuberculosis,  and  give  the  body  over  to  the  dread  enemy? 

2.  More  Remote  and  Secondary  Dangers.  The  masses  of  pla- 
centa or  membranes  retained  may  lead  to  the  formation  of  fibri- 
nous polypi,  which  produce  congestions  and  inflammations  of  the 
endometrium  with  fungous  granulations  and  thereby  protract 
the  bleeding  indefinitely.  Such  is  the  history  of  many  cases  in 
which  the  patients  become  chronic  invalids  or  fall  into  the  hands 
of  gynaecologists  who,  fortunately,  are  generally  able  to  cure  or 
greatly  relieve. 

3.  Danger  from  saprcemia  and  septiccemia  will  be  considered 
later. 

Treatment. — As  soon  as  possible  after  the  commencement  of 
the  haemorrhage  one  should  explore  the  uterus  and  remove  all 
offending  matters.  The  methods  of  conducting  this  procedure 
will  depend  on  the  circumstances  of  each  case;  but,  generally 
speaking,  the  best  instrument  for  the  purpose  is  the  intelligent 
finger  of  the  careful  obstetrician.  Up  to  the  second  week,  and 
generally  up  to  the  end  of  the  second  week,  it  is  usually  not  diffi- 
cult to  introduce  one  or  two  fingers  into  the  cavity  of  the  uterus. 
It  is  better,  as  a  rule,  to  have  an  anaesthetic  administered  by  an 
assistant.  This  saves  the  patient  much  suffering  and  enables  the 
operator  to  do  his  work  more  thoroughly.  During  the  third  or 
fourth  week  the  fingers  may  generally  be  pushed  through  the 
cervical  canal  by  using  a  certain  amount  of  force.  If  necessary 
use  an  artificial  dilator,  and  a  dull  curette  with  great  care. 

The  physician  should  not  try  to  stop  secondary  haemorrhages 
by  the  administration  of  medicines,  such  as  ergot,  quinine,  strych- 
nine, etc.,  before  he  has  thoroughly  explored  and  emptied  the 
uterus.  Always  give  medicines  of  this  sort  after  local  treatment 
has  been  carried  out.  They  help  to  bring  about  the  involution 
which  is  so  much  desired.     Never  give  up  an  obstetrical  case  while 


358     H^MOERHAGE  BEFOEE  AND  AFTEE  LABOE 

there  is  uterine  haemorrhage.  It  is  the  duty  of  the  obstetrician 
to  cure  the  patient  instead  of  letting  her  drift  into  the  hands  of  the 
gynsecologist.  If,  however,  he  is  unable  to  cure  the  patient  within 
a  reasonable  time  he  should  call  in  consultation  the  best  available 
gynsecologist. 


CHAPTER  XVI 

ABORTION  OR  MISCARRIAGE 

GENERAL  CONSIDERATIONS 

Use  of  Terms. — In  the  minds  of  the  pubhc  abortion  is  confined 
to  the  induced  operation — that  is,  the  abortion  brought  about  by 
artificial  interference.  Many  women,  both  in  towns  and  in  the 
rural  districts,  are  in  the  habit  of  inducing  abortions  by  puncturing 
the  egg  with  some  sharp  instrument,  such  as  a  knitting  needle  or 
hairpin.  Many  are  unsuccessful  in  these  attempts,  while  a  certain 
number  injure  themselves  very  seriously.  Death  is  sometimes  the 
result  of  such  criminal  procedure.  The  induction  of  abortion  by 
physicians  is  said  to  be  quite  common  in  certain  cities  and  towns 
of  this  continent. 

The  term  miscarriage,  on  the  other  hand,  is  applied  to  the 
emptying  of  the  uterus  from  natural  causes.  Some  limit  the  mean- 
ing of  abortion  to  the  discharge  of  the  embryo  during  the  first 
three  months  and  miscarriage  to  the  expulsion  of  the  foetus  be- 
tween the  end  of  the  third  and  the  end  of  the  seventh  month. 

The  term  abortion  is  generally  recognized  in  the  broader  sense 
in  medical  literature — that  is  to  say,  abortion  means  the  expulsion 
or  delivery  of  the  foetus  during  the  first  seven  months  of  pregnancy. 
One  should  be  careful  in  speaking  to  his  patients  to  use  the  word 
miscarriage  rather  than  abortion.  Some  women  feel  quite  offend- 
ed if  the  physician  hints  at  the  possibility  of  their  having  had  an 
abortion. 

Occurrence. — Abortion  occurs  most  frequently,  so  far  as  we 
know,  in  the  third  month.  This  is  probably  due  to  the  fact  that  at 
that  time  the  egg  is  to  some  extent  loosened  on  account  of  the 
atrophy  of  a  large  portion  of  the  chorionic  villi.  Next  to  the  third 
month  abortion  happens  most  frequently  in  the  second  and  fourth 
months.  Some  think  that  early  abortion  at  five  and  six  weeks, 
which  is  sometimes  not  recognized,  may  be  as  common  as  abortion 
in  the  third  month.     Such  early  abortion  does  undoubtedly  occur 

359 


360  ABORTIOI^    OR    MISCARRIAGE 

but  probably  not  so  frequently  as  supposed  by  some.  Up  to  the 
end  of  the  third  month,  or  nearly  so,  the  entire  ovum  is  generally 
expelled.  From  the  third  to  sixth  month  the  membranes  are  first 
ruptured,  then  the  foetus  is  generally  expelled,  and  finally  the  mem- 
branes and  placenta  may  be  disintegrated  and  come  away  gradually 
with  danger  of  septicaemia. 

Premature  Labor. — Premature  labor  means  termination  of 
pregnancy  between  the  end  of  seventh  month  and  full  term. 

The  foetus  is  viable  after  the  end  of  seventh  month — but  there 
are  some  exceptions  to  this.  Abortion  is  pra^ctically  equally  com- 
mon in  primiparse  and  multiparas. 

Causes. — The  causes  of  abortion  are  as  follows :  syphilis ; 
Bright 's  disease;  malposition  of  the  uterus,  especially  retroflexion; 
disease  of  decidua;  abortion  habit  from  unknown  causes;  dis- 
eases, such  as  exanthematous  fevers,  etc.;  excessive  vomiting; 
emotional  violence ;  mechanical  violence ;  death  of  foetus ;  haemor- 
rhage; overfrequent  coitus;  excesses  of  mother,  alcoholic,  etc.; 
tumors  of  uterus;  adhesions  of  uterus  from  old  pelvic  inflam- 
mations. 

Varieties. — Varieties  or  degrees  of  abortion  (Hirst) : 

1.  Ovum  when  thrown  off  may  be  surrounded  by  the  decidua, 
which  is  sometimes,  or  generally,  much  thickened.  In  the  majority 
of  cases  probably  the  decidua  vera  is  retained,  and  the  decidua 
reflexa,  or  a  portion  of  it,  goes  with  ovum. 

2.  Simply  the  entire  ovum  without  any  decidua.  When 
floated  in  water  villi  will  be  seen  and  the  whole  ovum  looks  like 
a  chestnut  burr. 

3.  Embryo  with  its  amnion  only. 

4.  Embryo  expelled  alone. 

5.  Embryo  may  die  and  be  absorbed  or  cast  off  unnoticed, 
leaving  behind  a  hollow  fleshy  mass,  which  may  become  a  mole. 

S)nnptoms. — The  symptoms  of  abortion  are :  haemorrhage,  pain 
with  uterine  contractions,  and  complete  or  partial  dilatation  of 
the  OS  uteri. 

Hcemorrhage  is  altogether  the  most  important  symptom  of 
abortion.  We  have  two  fairly  well  marked  types  of  cases  as  re- 
gards the  haemorrhage : 

1.  When  haemorrhage,  though  not  profuse,  continues  for  a 
long  time. 

2.  When  haemorrhage  is  copious  almost  or  quite  from  the  first. 


GENERAL    CONSIDERATIONS  361 

Certain  authors  state  that  tho  hfcmorrhago  in  early  abortion  is 
never  so  profuse  as  to  be  fatah  In  the  majority  of  cases  haemor- 
rhage is  not  profuse  even  when  it  continues  for  a  long  time. 
Occasionally,  however,  the  haemorrhage  is  quite  copious  even  at 
an  early  stage,  and  sometimes  proves  fatal  in  a  short  time. 

The  Aborting  Habit. — In  a  large  proportion  of  the  cases  the 
cause  of  the  so-called  aborting  habit  is  unknown.  In  all  such 
cases  rest  is  an  important  element  in  treatment.  It  is  not  well, 
however,  to  keep  a  patient  continuously  in  bed  during  pregnancy, 
because  it  is  apt  to  injure  her  own  health  and  also  that  of  her  un- 
born child,  but  it  is  well  to  keep  her  in  bed  during  the  week  corre- 
sponding to  the  time  of  the  ordinary  menstrual  period. 

Garrigues  reports  one  case  in  which  nine  abortions  were  finally 
followed  by  the  birth  of  a  child  at  term,  and  says  that  he  has  fre- 
quently prevented  abortion  by  having  the  patient  rest  two  days 
before  menstruation  should  occur  and  continue  in  bed  five  days 
thereafter.  During  this  week  he  gives  dram  doses  of  the  extract 
of  viburnum  pnmifolium  three  times  a  day.  During  the  other 
three  weeks  he  allows  moderate  exercise  in  the  open  air  and  gives 
tonics,  such  as  iron,  quinine,  red  bone  marrow,  and  arsenic. 

Coition,  dancing,  horseback  riding,  and  all  sorts  of  sports  or 
fatiguing  work  should  be  forbidden.  Sir  J.  Y.  Simpson  recom- 
mended the  continuous  administration  of  chlorate  of  potassium 
15  to  20  grains  three  times  a  day  for  some  months.  I  have  not 
had  much  success  with  the  chlorate  of  potash  treatment,  but  some 
of  my  friends  have  great  faith  in  it. 

Prophylactic  Treatment.     For  so-called  aborting  habit. 

The  patient  must  avoid  excesses  of  all  kinds,  and  remain  in 
bed  during  the  first  three  or  four  menstrual  epochs. 

If  there  is  syphilitic  taint  or  even  a  suspicion  of  it  place  patient 
under  constitutional  treatment.  After  an  abortion  has  occurred 
give  husband  and  wife  constitutional  treatment  in  order  to  avoid 
a  repetition. 

In  case  of  retroversion  or  retroflexion  correct  displacement  and 
if  necessary  introduce  a  suitable  pessary  and  leave  it  until  about 
the  middle  of  the  fourth  month.  A  woman  prone  to  abort  should 
avoid  coitus  during  the  whole  of  pregnancy;  also  strong  purga- 
tives and  vaginal  douching. 


362  ABOETION    OR    MISCARRIAGE 

THREATENED  ABORTION 

Rules  for  Treatment. — When  heemorrhage  is  not  severe,  the 
cervix  is  not  dilated,  and  there  is  no  evidence  of  the  escape  of  Hquor 
amnii,  efforts  may  be  made  to  prevent  abortion. 

Keep  patient  on  her  back  in  bed.  Give  an  opiate,  preferably 
by  the  bowel.  Give  with  the  opiate  bromide  and  chloral,  or  give 
with  the  opiate  viburnum  prunifolium.  Correct  displacement  of 
uterus  if  present.  When  hsemorrhage  persists  small  doses  of  ergot 
may  be  given  with  the  opiate.  Keep  patient  in  bed  for  one  week 
after  the  hsemorrhage  ceases.  There  is  not  much  to  add  to  these 
brief  directions  as  to  the  treatment  of  threatened  abortion.  One 
should  rely  chiefly  on  rest  and  opiates,  and  with  these  one  may 
use  some  form  of  viburnum  prunifolium.  How  much  good  the 
latter  does  I  am  unable  to  say  as  I  have  never  given  it  without  the 
opiate,  nor  do  I  think  I  ever  shall.  The  hsemorrhage  may  con- 
tinue for  a  long  time  without  cutting  short  the  pregnancy.  Some 
years  ago  I  was  much  puzzled  over  the  following  case : 

Mrs.  K.,  aged  thirty-two.  Married  nine  years.  Became  pregnant  for 
the  first  time.  In  third  month  hsemorrhage  commenced  and  continued 
for  eleven  weeks,  during  which  time  she  remained  in  bed.  Was  told  by 
a  physician  she  had  a  "false  conception  "  but  that  the  uterus  was  emptied 
and  she  was  cured.  I  saw  her  at  the  end  of  seventh  month  for  the  first 
time.  She  was  much  alarmed  on  account  of  enlargement  of  her  abdomen. 
Diagnosis  very  easily  made,  pregnancy  with  a  vigorous  foetus.  Healthy 
child  delivered  with  forceps  at  full  term. 

False  conception  is  rather  an  absurd  term  which  has  sometimes 
been  applied  to  some  form  of  fleshy  mole  due  to  the  death  of  the 
ovum. 

INEVITABLE  ABORTION 

Diagnosis. — When  ovum  protrudes  through  os.  When  liquor 
amnii  has  certainly  escaped.  When  hsemorrhage  is  excessive. 
When  the  rather  acute  angle  anteriorly  between  the  neck  and  the 
body  of  the  uterus  has  disappeared. 


TREATMENT 

Methods. — The  treatment  of  inevitable  abortion  is  different 
from  that  of  threatened  abortion,  which  we  try  to  prevent.     Our 


INEVITABLE    ABORTION  363 

desire  in  inevitable  abortion  is  to  have  the  uterus  emptied  com- 
pletely and  as  soon  as  possible  without  using  undue  violence. 
Directions  as  to  treatment  may  be  summarized  as  follows : 
There  are  two  methods  of  treatment  generally  recognized. 

1.  Expectant.  Watching  the  patient  carefully,  keeping  her 
quiet,  and  leaving  her  alone  until  interference  is  indicated  on  ac- 
count of  serious  haemorrhage  or  septic  infection,  with  the  hope 
that  Nature  through  the  uterine  contractions  will  completely  and 
safely  empty  the  uterus. 

2.  Immediate  active  interference  with  the  object  of  emptying 
the  uterus  as  quickly  as  possible. 

Methods  of  Active  Interference.— The  most  common  methods 
of  active  interference  are :  (a)  Tamponade.  Plugging  the  vagina 
or  vagina  and  uterus  (so  far  as  possible  as  to  the  latter)  wdth  the 
object  of  stopping  haemorrhage,  dilating  the  cervical  canal,  and 
causing  reflex  contractions  and  subsequent  emptying  of  the  uterine 
cavity.  (6)  Curettement.  The  most  popular  and  efficient  plan 
is  to  anaesthetize  the  patient,  sterilize  the  parts,  dilate  the  cervical 
canal,  and  empty  the  uterus  with  the  finger  or  an  ordinary  metallic 
curette. 

The  intelligent  and  educated  finger-tip  is  far  better  than  any 
metallic  curette  and  may  be  used  in  the  "  expectant"  plan  or  after 
the  tamponade  or  in  rapid  curettement.  Sometimes  a  dull  metal- 
lic curette  or  the  flushing  curette  may  be  used  when  the  finger  can 
not  be  introduced  into  the  uterus.  Uterine  or  placental  forceps 
are  sometimes  used. 

After  the  finger  has  been  introduced  into  the  uterus  the  abor- 
tion should  be  completed  as  soon  as  possible. 

It  is  frequently  a  difficult  matter  to  come  to  a  decision  as  to 
when  we  should  cease  to  consider  that  an  abortion  is  simply 
threatened,  and  decide  that  it  is  inevitable.  Even  after  we  reach 
our  decision  we  may  have  some  difficulty  in  deciding  on  a  plan  of 
treatment.  Obstetricians  vary  greatly  as  to  their  opinion  of 
treatment,  and  in  a  general  way  may  be  said  to  be  divided  into 
two  camps — that  is,  those  who  believe  in  expectant  treatment  and 
those  who  believe  in  active  interference ;  and  yet  a  large  number 
may  be  found  who  are  not  tied  to  either  the  one  or  other  form  of 
treatment. 

The  Expectant  Plan  of  Treatment. — The  term  expectant  is  not 
a  very  fitting  one,  and  is  sometimes  grossly  misunderstood  even  by 


364  ABOETION    OR    MISCAERIAGE 

physicians  who  ought  to  have  a  fair  knowledge  of  obstetrical  liter- 
ature. A  gynaecologist  of  this  province  about  two  years  ago  spoke 
as  follows : 

' '  In  my  early  experience  cases  of  abortion  were  treated  on  the 
so-called  expectant  plan,  a  wretched  makeshift,  and  one  that 
should  never  be  entertained.  This  plan  consists  of  daily  visits  by 
the  doctor,  who  trusts  entirely  to  Dame  Nature  without  giving  her 
any  assistance.  When  fever  sets  in  it  is  looked  upon  as  a  calamity 
that  could  not  be  avoided.  The  mother  dies  from  what  is  called 
a  bad  miscarriage  and  a  life  is  lost  that  could  have  been  spared." 

This  description  of  the  expectant  plan  is  incorrect.  No  ob- 
stetrician of  any  note  has  advised  any  such  method  of  treatment 
within  the  last  forty  years.  According  to  the  expectant  plan  the 
physician  waits  to  see  if  Nature  can  complete  her  work;  if  not  he 
promptly  assists  her  to  the  best  of  his  ability.  It  is  generally 
understood  among  those  who  favor  this  method  that  active  inter- 
ference is  absolutely  necessary  when  haemorrhage  becomes  serious, 
or  when  the  slightest  symptom  of  septic  infection  appears. 

Lusk  was  perhaps  the  most  prominent  advocate  of  the  expect- 
ant plan  of  treatment  on  this  continent.  He  told  us  that  when  in 
the  third  month  the  ovum  is  thrown  off  without  rupture  of  the 
foetal  membranes  the  haemorrhage  rarely  assumes  dangerous  pro- 
portions, and  explained  how  the  uterine  contractions  sometimes 
press  the  ovum  into  the  cervix,  which  dilates  and  in  primiparae 
becomes  somewhat  elongated.  During  uterine  contractions  the 
ovum  descends  and  the  upper  portion  of  the  body  of  the  uterus 
retracts.  Some  coagulation  of  the  blood  takes  place  between  the 
ovum  and  the  retracted  uterine  walls,  while  the  ovum  forms  a 
tampon  which  fills  the  cervix  like  a  ball  valve,  and  thus  restrains 
the  haemorrhage.  When  there  is  no  interference  the  egg,  after 
being  retained  for  a  time  as  described,  is  frequently  expelled  entire, 
leaving  the  uterus  in  the  best  possible  condition  for  satisfactory 
involution.  In  such  cases,  and  they  are  by  no  means  uncommon. 
Nature  has  done  her  work  safely  and  efficiently.  Lusk's  views  on 
treatment  are  in  certain  respects  open  to  criticism.  The  following 
directions  will  probably  meet  the  approval  of  most  of  those  who 
advise  the  so-called  expectant  treatment : 

When  to  Interfere. — Always  interfere  when  the  os  and  cervical 
canal  are  sufficiently  dilated  to  allow  the  introduction  of  the  fin- 
ger into  the  uterine  cavity.     In  attempting  to  remove  the  uterine 


INEVITABLE    ABORTION  365 

contents  with  the  finger  one  should  adopt  the  following  definite 
plan  of  action  and  always  presume,  unless  there  is  positive  proof 
to  the  contrary,  that  the  ovum  is  intact,  and  should  not  be 
broken : 

Place  the  patient  in  .the  lithotomy  position,  preferably  ' '  across- 
bed,"  and  with  the  external  hand  endeavor  to  depress  the  uterus 
through  the  abdominal  wall  until  the  index  finger  of  the  other  hand 
can  be  passed  through  the  os  and  up  to  the  fundus.  Anaesthesia 
is  not  necessary  in  the  majority  of  cases,  but  is  not  infrequently 
either  required  or  desirable.  In  the  manipulations  try  to  avoid 
rupturing  the  ovum.  Pass  the  finger  up  on  lateral  wall  of  the 
uterus  until  it  is  above  the  egg,  at  or  near  the  opening  of  one  Fal- 
lopian tube,  then  pass  it  across  the  fundus  to  the  neighborhood  of 
the  opening  of  the  other  Fallopian  tube,  and  sweep  down  this  wall, 
driving  the  contents  of  the  uterus  before  it.  If  unable  to  remove 
the  uterine  contents  by  the  finger  in  this  way  one  should  try  the 
following  Rotunda  procedure :  take  the  finger  out  of  the  uterus  and 
place  it  under  the  fundus — i.  e.,  in  the  anteinor  fornix  if  the  uterus 
is  normal  in  position,  in  the  posterior  fornix  if  the  uterus  is  retro- 
verted.  Sink  the  other  hand  into  the  abdomen  and  compress  the 
body  between  the  two  hands.  The  ovum  is  thus  driven  out  of  the 
uterus  into  the  vagina  and  removed  (Jellett). 

It  is  well  to  remember  in  this  connection  that  there  is  a  period 
between  early  and  late  abortion,  say  in  the  latter  part  of  the  third 
month,  when  it  is  difficult  with  the  finger-tip  to  make  out  the 
placenta,  because  it  feels  exactly  like  the  endometrium.  It  is 
possible,  under  such  circumstances,  to  make  the  mistake  of  imagin- 
ing that  the  uterus  is  empty  wliile  the  thin  broad  placenta  is  com- 
pletely adherent.  In  such  a  case  it  is  better  to  try  to  remove  this 
placenta  by  scraping  with  the  finger-tip.  In  case  of  failure  it  is 
better  to  use  the  flushing  or  ordinary  dull  curette. 

When  immediate  active  interference  is  considered  necessary 
tamponade  or  curettement  should  be  done. 

Treatment  by  Tamponade. — Treatment  by  tamponade  is  in  the 
opinion  of  many  the  safest  and  best  form  in  all  varieties  of  inevi- 
table abortion,  whether  complete  or  incomplete,  excepting  in  cer- 
tain cases  of  septic  infection  where  it  is  advisable  to  empty  the 
uterus  as  quickly  as  possible  with  the  finger  or  some  form  of  curette. 

There  are  two  forms  of  tamponade:  1,  vaginal  tamponade;  2, 
utero-vaginal  tamponade. 


366  ABORTION    OR    MISCARRIAGE 

Vaginal  Tamponade. — A  vaginal  tampon  in  order  to  be  effective 
should  be  properly  introduced,  but  I  fear  that  in  a  majority  of 
instances  the  vaginal  tamponade  is  not  properly  done.  In  the 
first  place  the  material  used  should  be  made  antiseptic,  because 
a  simple  sterile  tampon  in  the  vagina  very  soon  becomes  foul. 
We  may  accept  the  conclusions  of  Kronig  and  Williams  that  there 
are  no  pathogenic  cocci  in  the  vaginal  secretions  of  a  healthy 
woman  during  pregnancy.  There  are,  however,  bacteria,  which, 
although  harmless  as  a  rule,  are  not  always  innocuous,  because 
under  certain  circumstances  they  cause  putrefaction. 

Schauta's  Method. — Take  a  strip  of  iodoform  gauze  about  two 
yards  long  and  three  to  four  finger-breadths  wide,  and  firmly  pack 
the  entire  vault  of  the  vagina,  allowing  the  end  to  hang  out  of  the 
vulva.  Schauta  thought  that  two  fingers  of  the  other  hand  form 
a  better  guide  in  tamponing  than  a  speculum.  If  sacral  pains 
occur,  indicating  that  the  embryo  has  been  expelled,  the  tampon 
may  be  pulled  out ;  if  such  pains  do  not  occur  the  tampon  should 
be  removed  in  twenty-four  hours.  If  the  abortion  is  not  complete 
and  bleeding  still  exists,  it  should  be  replaced,  especially  if  the  os 
is  more  dilated  than  the  day  before.  Tamponing  may  be  safely 
kept  up  many  days  if  the  tampon  is  renewed  every  twenty-four 
hours.  In  this  way,  as  a  rule,  the  intact  ovum  is  obtained,  whereas 
by  some  energetic  efforts  it  is  crushed.  If,  however,  under  the 
tamponing  the  os  is  dilated  so  as  to  admit  two  fingers  and  the 
ovum  does  not  come  away,  one  should  interfere  actively.  If 
bleeding  still  continues,  the  utero-vaginal  tamponade,  as  hereafter 
described,  may  be  tried. 

Utero-Vaginal  Tamponade. — In  using  a  tampon  we  expect  the 
following  results:  (1)  It  stops  haemorrhage.  (2)  It  assists  fur- 
ther separation  of  the  ovum  by  damming  up  the  blood.  (3)  It 
excites  uterine  contraction  and  retraction.  (4)  It  dilates  the  cer- 
vical canal. 

Diihrssen  believes  that  these  results  can  be  obtained  with 
greater  certainty  and  safety  by  plugging  the  utero-vaginal  canal 
than  by  tamponade  of  the  vagina  only.  In  late  abortions  the 
results  are  especially  good,  better  in  all  respects  and  in  all  cases 
than  by  curettement  alone. 

The  method  consists  of  stuffing  as  much  iodoform  gauze  as 
possible  into  the  uterine  cavity  and  then  thoroughly  plugging  the 
vagina. 


INEVITABLE    ABORTION  367 

I  should  recommend  this  kind  of  tamponade  in  all  cases  where 
it  can  be  done.  Frequently  it  is  not  possible  at  first,  but  when 
one  removes  a  vaginal  plug  after  twenty-four  hours,  it  is  almost 
always  easy  when  introducing  a  second  plug  to  pass  some  of  the 
gauze  into  the  uterus,  .or,  in  other  words,  after  a  vaginal  plug  has 
been  in  place  twenty-four  hours  it  is  easy  after  its  removal  to  do 
a  utero-vaginal  tamponade  instead  of  a  simple  vaginal  tampon- 
ade. There  are  many  differences  of  opinion  as  to  detail  with 
reference  to  tamponade,  as  the  following  paragraphs  will  show: 

A  Dublin  physician  tells  us  the  dangers  of  plugging  the  vagina, 
unless  the  plugging  is  aseptically  performed,  are  considerable,  and 
even  if  the  plug  itself  is  aseptic,  blood  may  stagnate  above  it,  and 
putrefy.  The  decomposition  then  extends  to  the  uterus,  and 
tliough  the  patient  seldom  dies,  as  a  result  she  is  frequently  left  an 
invalid  for  years  from  tubal  disease  and  pelvic  peritonitis. 

An  Edinburgh  physician  tells  us  that  in  plugging  we  should 
use  strips  of  antiseptic  gauze,  or  of  any  soft  textile  material  ren- 
dered aseptic  by  boiling  or  immersion  in  an  antiseptic  solution. 

A  London  physician  tells  us  to  douche  the  vagina  with  bi- 
chloride of  mercury  1-2000  before  tamponade,  and  to  soak  the 
material  used  in  a  similar  solution  before  introducing  it.  Nearly 
all  the  obstetricians  of  Great  Britain  tell  us  that  a  tampon  should 
not  be  left  in  the  vagina  longer  than  eight,  ten,  or  twelve 
hours. 

A  Toronto  physician  tells  us  that  iodoform  gauze  should  not 
be  left  in  the  uterus,  because  it  is  apt  to  poison  the  patient.  Many 
of  the  American  authors  advise  us  to  use  iodoform  gauze  and  to 
leave  it  in  from  twenty-four  to  forty-eight  hours,  but  very  few  of 
them  speak  clearly  as  to  utero-vaginal  tamponade.  Garrigues 
uses  iodoform  gauze  to  some  extent,  but  he  considers  it  too  porous 
to  form  a  rehable  antihsemorrhagic  plug.  He  only  uses  it  when 
there  is  a  partial  dilatation  of  the  cervical  canal,  then  he  fills  this 
with  iodoform  gauze  and  considers  that  it  is  well  adapted  for  the 
purpose,  on  account  of  its  softness.  He  also,  in  some  cases, 
placed  a  pledget  of  iodoform  gauze  at  the  vault  of  the  vagina  cov- 
ering the  OS.  This  objection  to  iodoform  gauze  is  worthy  of  con- 
sideration. Sometimes  gauze  is  used  which  is  very  coarse  in  tex- 
ture and  poor  in  quahty.  I  think  it  exceedingly  hard  to  make  a 
dense  plug  with  such  material.  I  think,  however,  good  iodoform 
gauze  generally  m.akes  an  efficient  plug,  as  the  amount  of  serum- 
25 


368  ABOETION    OE    MISCAEEIAGE 

like  fluid  which  passes  through  such  a  plug  is  not  likely  to  be  very- 
harmful . 

Rules. — With  reference  to  the  various  points  raised,  the  follow- 
ing rules  may  assist  the  accoucheur  in  practise: 

Asepsis  without  antisepsis  is  not  safe  in  vaginal  or  vagino- 
uterine  tamponade. 

''Any  soft  textile  material  rendered  aseptic  by  boiling  "  is  not 
safe  for  such  tamponade. 

A  solution  of  bichloride  of  mercury  is  not  suitable  for  douch- 
ing before  tamponade  nor  for  medicating  the  tampon,  because  it 
tends  to  unduly  harden  the  tissues. 

The  best  material  for  tamponade  is  iodoform  gauze  or  cotton. 
Sterile  cotton  soaked  in  a  1  per  cent,  solution  of  lysol  also  answers 
well. 

A  tampon  of  iodoform  gauze  may  with  safety  be  left  in  the 
vagino-uterine  canal  one  or  two  days.  Iodoform  is  slightly  poison- 
ous, but  the  danger  of  serious  poisoning  when  used  as  indicated  is 
not  worth  considering.  Some  gynaecologists  leave  iodoform  gauze 
in  the  peritoneal  cavity  a  week  without  evil  consequences.  A 
simple  aseptic  tampon  should  not  be  left  in  the  vagina  longer 
than  eight  to  twelve  hours. 

Curettement. — In  the  hands  of  an  expert  this  is  a  compar- 
atively safe  and  very  effective  method  of  quickly  emptying  the 
uterine  cavity.  It  is,  however,  a  difficult  operation  to  perform 
(much  more  so  than  the  amputation  of  a  leg),  and  also  involves 
a  considerable  amount  of  danger,  especially  in  unskilled  hands. 
If  for  some  reason  it  is  considered  very  important  to  empty  the 
uterus  quickly,  rapid  curettement  under  anaesthesia  is  practically 
a  necessity.  This  is  especially  true  in  some  cases  of  septic  abor- 
tion. After  such  curettement  the  introduction  of  iodoform  gauze 
into  the  uterine  cavity  is  always  advisable. 

I  shall  briefly  refer  to  some  aspects  of  abortion  from  a  clinical 
standpoint. 

One  is  called  to  see  Mrs.  A.,  aged  twenty-five,  in  third  month  of 
pregnancy.  She  has  had  some  uterine  haemorrhage  for  twenty- 
four  hours,  with  some  pain.  What  is  the  diagnosis?  She  has 
symptoms  of  abortion.  What  is  the  proper  treatment?  Before 
deciding  on  any  line  of  treatment  the  following  question  should  be 
considered :  Can  abortion  be  prevented  ?  Let  us  suppose,  in  the 
first  place,  that  the  haemorrhage  is  not  serious,  and  on  examination 


INEVITABLE    ABORTION  369 

that  the  os  is  not  patent.  The  physician  thinks  or  hopes  that 
abortion  is  preventable,  and  will  make  an  effort  to  prevent  it.  He 
will  keep  the  patient  in  bed,  give  her  opiates — say,  a  suppository  of 
1  to  2  grains  of  opium  every  four  to  eight  hours — and  at  the  same 
time  see  that  the  bowels  are  kept  open  by  some  saline  aperient. 
He  will  also  give  some  preparation  of  viburnum  prunifolium,  or 
bromide,  or  chloral  by  the  mouth.  If  the  pains  and  haemorrhage 
cease,  he  may  consider  that  the  treatment  is  successful.  The  pa- 
tient who  has  suffered  but  little  and  lost  but  little  blood  will  prob- 
ably be  anxious  to  get  up.  How  long  should  she  remain  in  bed? 
Not  less  than  seven  to  ten  days  after  haemorrhage  ceases. 

In  another  case  there  is  serious  haemorrhage  and  perhaps  the 
OS  is  patulous.  The  haemorrhage  is  here  the  important  symptom 
and  must  be  checked.  The  physician  decides  that  the  uterus 
must  be  emptied — that  is,  that  abortion  is  inevitable.  If  the  fin- 
ger can  enter  the  uterus  he  will  clear  out  the  contents  at  once. 
Anaesthesia  may  be  necessary.  One  may  be  able,  with  the  finger, 
to  clear  out  most  of  the  contents  of  the  uterus,  but  may  not  be 
able  to  quite  reach  the  fundus.  He  has  removed  most  of  the 
uterine  contents,  but  fears  that  something  is  retained  near  the 
fundus.  In  such  a  case  he  should  introduce  a  vagino-uterine 
tampon  or  use  a  curette. 

If  the  cervical  canal  is  not  sufficiently  dilated  to  allow  the 
introduction  of  the  finger,  it  is  well  to  introduce  a  tampon  of  iodo- 
form gauze  into  the  vagina.  In  early  abortion  one  may  hope  to 
stop  the  haemorrhage,  cause  uterine  contractions,  and  dilate  the 
cervix.  On  removing  the  tampon  the  following  day  the  operator 
may  find  the  egg  entire  in  the  vault  of  the  vagina.  If  so,  the  abor- 
tion is  now  complete  and  the  patient  is  practically  well. 

If,  on  the  other  hand,  after  removing  the  tampon  he  finds 
neither  the  egg  nor  any  portion  of  it  in  the  vagina,  he  should  ascer- 
tain the  condition  of  the  cervical  canal.  If  it  is  dilated  sufficiently 
to  admit  the  finger  he  should  endeavor  to  clear  out  the  contents. 
If  unable  to  do  this,  he  should  try  tamponade  of  both  uterus  and 
vagina.  He  should  remove  the  tampon  again  in  twenty-four 
hours.  By  this  time  he  will  probably  find  the  uterus  empty,  or 
the  condition  such  that  he  can  readily  empty  it.  If  still  in  doubt 
as  to  whether  the  uterus  is  empty,  he  should  curette,  using  first, 
finger-tip ;  second,  metallic  dull  curette  if  necessary. 

While  many  object  to  the  use  of  the  metalhc  curette,  except 


370 


ABOETION    OE    MISCAERIAGE 


as  a  last  resort,  some  of  our  best  obstetricians  use  it  quite  com- 
monly. Even  in  conservative  Rotunda  curettement  is  done  in 
nearly  50  per  cent,  of  the  cases  of  abortion.  At  a  certain  medical 
society  meeting  two  years  ago,  in  reply  to  some  adverse  criticism 
as  to  such  frequent  curettement,  Jellett  stated  that  although  he 

could  not  say  the  curet- 
ting had  led  to  any  bad 
results,  he  thought  they 
would  do  wrong  if  they 
sent  out  men  with  the 
idea  that  50  per  cent,  of 
abortions  required  curet- 
ting. 

After  -  Treatment  of 
Abortion. — Keep  patient 
in  bed  not  less  than  a 
week  after  the  comple- 
tion of  the  abortion,  and 
longer  if  the  lochial  dis- 
charges remain  copious. 
Some  think  that  the 
uterus  after  abortion  is 
not  well  prepared  for  in- 
volution. A  slight  loch- 
ial discharge  usually  per- 
sists for  about  three 
times  as  many  days  as 
the  gestation  has  lasted 
months. 

Missed  Abortion.  — 
When  ovum  dies  but  is 
not  expelled,  it  may  be 
retained  in  the  uterus  without  giving  rise  to  serious  symptoms 
for  weeks,  months,  or  possibly  for  more  than  a  year. 

The  subject  of  missed  abortion  is  an  extremely  interesting  one 
from  various  points  of  view.  We  now  know  that  a  dead  ovum 
may  be  retained  in  the  uterus  without  any  change  in  structure  for 
months  and  possibly  years.  Formerly  the  limit  was  supposed  to 
be  nine  months.  It  has,  however,  been  proved  that  the  limit 
may  be  much  longer. 


Fig.  131. — Mass  of  Placenta  retained  in 
Uterus  Fourteen  Months.  (Algernon 
Temple,  Tor.  Univ.  Museum.) 


INEVITABLE    ABORTION  371 

In  the  case  of  Kitson  vs.  Playfair  a  uterus  was  emptied  in 
February,  1894.  Dr.  Playfair  contended  that  the  substance 
removed  was  a  comj)arativcly  fresh  piece  of  placenta  remaining 
in  the  uterus  after  a  recent  incomplete  abortion.  On  the  other 
hand,  it  was  contended  by  able  and  competent  obstetricians  that 
the  substance  removed  might  have  been  the  result  of  a  conception 
at  least  eighteen  months  before,  and  was  part  of  a  blighted  ovum 
which  perished  in  October,  1892,  which  had  been  retained  in  the 
uterus  for  sixteen  months. 

In  a  certain  proportion  of  cases  the  fa3tus  may  die  without 
any  serious  symptoms  until  nine  months  after  conception,  when 
labor  comes  on  and  the  uterus  is  emptied  without  artificial  assist- 
ance.    The  following  is  an  example: 

A  patient  of  Dr.  Walters,  East  York,  had  some  pains  and  a  slight 
haemorrhagic  discharge  in  fifth  month  of  pregnancy.  After  a  few  days' 
rest  in  bed  the  pains  and  haemorrhage  stopped  completely.  She  had  no 
further  symptoms  and  no  abdominal  enlargement  for  months  after.  The 
patient  was  watched  with  a  certain  amount  of  anxiety  but  appeared  to  be 
in  her  usual  health.  At  full  time  labor  pains  came  on  spontaneously  and 
a  five  months'  dead  foetus  was  expelled. 

There  is  considerable  difference  of  opinion  as  to  what  should 
be  done  under  such  circumstances.  Some  think  that  the  patient 
should  be  left  alone  in  the  absence  of  disturbing  symptoms;  others 
think  that  it  is  always  desirable  to  empty  the  uterus  when  the 
death  of  the  foetus  has  been  diagnosed  with  certainty. 

I  do  not  know  why,  in  certain  cases,  labor  pains  come  on  at 
full  time,  while  in  other  cases  the  blighted  ovum  is  retained  for 
one  or  two  years,  but  think  that  the  blighted  ovum  of  early  preg- 
nancy is  more  apt  to  be  retained  for  an  indefinite  time,  while 
that  of  later  pregnancy  is  apt  to  be  expelled  at  or  about  full  time. 

Treatment.  I  think  that  it  is  better  not  to  interfere,  as  a  rule^ 
when  there  are  no  serious  symptoms,  especially  as  in  a  large  pro- 
portion of  cases  there  is  a  certain  element  of  doubt  as  to  diagnosis. 
We  find  in  practice  that  it  is  no  easy  matter  in  all  cases  to  make 
a  diagnosis  of  death  of  the  foetus.  There  can  be  no  difference  of 
opinion,  however,  as  to  the  fact  that  when  serious  symptoms 
arise  one  should  always  empty  the  uterus  as  soon  as  possible. 

In  my  references  to  the  treatment  of  abortion  I  have  always 
had  in  view  those  cases  which  occur  in  the  first  half  of  pregnancy. 


372  ABOETION    OR    MISCARRIAGE 

From  the  fifth  month  one  should  conduct  the  abortion  as  in  labor 
at  full  time. 

OTHER  VARIETIES  OF  ABORTION 

There  are  some  other  technical  terms  applied  to  different  vari- 
eties of  abortion  to  which  brief  reference  may  be  made.  It  should 
be  remembered  in  the  same  connection  (as  before  mentioned) 
that  in  abortion  the  separation  generally  takes  place  in  the  spongy 
or  middle  layer  of  the  decidua,  but  occasionally  in  the  compact 
or  superficial  layer. 

Complete  Abortion. — All  within  the  spongy  layer  comes  away 
— i.  e.,  the  membranes  (including  part  of  decidua  vera  and  decidua 
serotina,  decidua  reflexa,  chorion,  and  amnion),  placenta,  and 
embryo  or  foetus. 

Incomplete  Abortion. — Some  one  or  more  of  these  structures 
are  retained  in  the  uterus.  In  considering  the  treatment  of 
incomplete  abortion  the  following  division  of  abortion  is  of  some 
importance : 

Early  abortion — before  tenth  week. 

Late  abortion — after  the  tenth  week. 

Active  interference  is  desirable  as  a  rule,  because  after  the 
ovum  sac  is  burst  septic  infection  is  apt  to  occur.  Curettement  is 
suitable  in  some  cases  of  early  incomplete  abortion.  Utero- vaginal 
tamponade  is  better  in  late  incomplete  abortion. 

Neglected  Abortion. — When  a  patient  has  haemorrhage  and 
other  symptoms  of  abortion  for  some  days  or  weeks  without  any 
treatment,  perhaps  without  ever  consulting  a  physician. 

Treatment.  Active  interference  is  desirable,  as  this  is  an  incom- 
plete abortion  with  great  probability  of  septic  infection. 

Cervical  Abortion. — This  term  is  applied  by  some  to  a  condi- 
tion in  which  the  ovum  is  expelled  into  the  cervix.  In  multip- 
arse  the  ovum  is  generally  soon  expelled,  but  in  primiparse  it  may 
remain  for  days  on  account  of  slow  dilatation  of  external  os. 

Treatment.  Dilate  external  os  with  finger,  cervical  tampon- 
ade, or  a  steel  divulsor.  Lateral  incisions  of  the  os  are  recom- 
mended by  some  in  stubborn  stricture. 

Deciduoma  Malignum  or  Chorio-Epithelioma. — Deciduoma 
malignum  was  the  name  given  by  Sanger  in  1888  to  a  very  malig- 
nant tumor  of  the  uterus  which  he  supposed  to  be  a  sarcoma  of 
the  decidua  serotina.     Many  surgeons  refused  to  accept  the  opinion 


DECIDUOMA    MALIGXUM  373 

that  this  tumor  was  a  distinct  pathological  entity,  and  expressed 
the  view  that  it  was  simply  an  ordinary  sarcoma  developed  at  the 
placental  site.  There  was  much  confusion  and  difference  of  opin- 
ion on  the  subject  for  years,  but  Marchand  threw  much  light  on 
the  matter  in  a  first  publication  in  1895,  and  a  second  in  1S98. 

According  to  Marchand 's  views  which  are  now  generally  ac- 
cepted, the  growth  is  extremely  malignant,  but  not  a  sarcoma. 
It  is  an  epithelioma  developed  from  the  epithelial  layers  covering 
the  chorionic  villi.  To  speak  more  precisely,  it  arises  from  the 
Langhan's  layer  and  the  syncytial  layer,  both  of  which  are  of 
epiblastic  origin. 

McMurtry  points  out  clearly  that  clinically  the  disease  pre- 
sents a  distinct  history.  Haemorrhage  is  the  first  and  most  per- 
sistent symptom,  and  is  not  controlled  by  curettage.  The  flow 
is  at  first  red,  but  soon  becomes  dark  and  offensive.  Pain  is  fre- 
quently present.  The  uterus  is  enlarged  and  soft,  with  the  os 
patulous.  There  is  generally  early  metastasis.  The  metastatic 
deposits  consist  of  the  same  elements  as  the  primary  tumor,  but 
grow  more  rapidly.  They  are  found  most  commonly  in  the  lungs 
and  vagina.  Death  generally  occurs  within  a  few  months  after 
the  initial  haemorrhage.  It  frequently  follows  hydatid-mole  preg- 
nancy, but  in  a  certain  proportion  of  cases  (not  now  known)  follows 
ordinary  abortion,  full-time  labor,  and  ectopic  pregnancy. 

In  September,  1900,  I  saw  a  patient  supposed  to  be  nine  or  ten 
weeks  advanced  in  pregnancy.  The  chief  symptom  was  slight 
haemorrhage,  and  the  uterus  was  enlarged  and  retrofiexed.  On 
account  of  my  illness,  which  commenced  in  October,  I  did  not  see 
her  again.  She  was  treated  by  Dr.  Herbert  Hamilton.  A  few 
months  later  hysterectomy  was  performed  by  Drs.  Hamilton  and 
Temple,  but  she  died  shortly  after  from  the  metastatic  growths. 
Careful  examination  of  the  primary  growth  by  Dr.  G.  C.  Wagner 
showed  that  it  was  deciduoma  malignum. 

It  is  now  generally  believed  that  the  term  deciduoma  malig- 
num is  really  a  misnomer,  and  that  the  name  suggested  by  Mar- 
chand— chorio-epithelioma — which  is  commonly  used  now  on  the 
Continent  of  Europe,  is  more  suitable.  The  term  deciduoma 
malignum,  however,  is  more  commonly  used  in  England,  the 
United  States,  and  Canada. 

Treatment.  Early  and  complete  hysterectomy  should  be  per- 
formed. 


CHAPTER  XVII 

PROLONGED  AND  PRECIPITATE  LABOR 

PROLONGED  LABOR 

When  the  obstetrician  visits  St.  George's  Chapel,  Windsor 
Castle,  let  him  not  forget  to  view  the  cenotaph  of  the  Princess 
Charlotte.  This  monument,  built  in  memory  of  one  of  England's 
most  dearly  beloved  women,  serves  also  as  a  memorial  of  the 
saddest  obstetrical  calamity  recorded  in  British  history.  All 
England,  in  1817,  was  waiting  for  a  happy  termination  of  the  Prin- 
cess Charlotte's  pregnancy.  The  membranes  were  ruptured  on 
Monday  at  7  p.  m.  Labor  pains  followed  soon  after  and  continued 
in  varying  degrees  for  fifty  hours.  There  is  every  reason  to  sup- 
pose that  in  this  "  dry"  labor  the  uterine  contractions  were  accom- 
panied by  more  than  the  average  amount  of  suffering.  The  first 
stage  probably  lasted  about  ten  to  twelve  hours;  the  second 
stage,  thirty-eight  to  forty  hours.  The  three  distinguished  physi- 
cians in  charge  decided  that  ''giving  assistance  was  quite  out  of 
the  question,"  as  the  "labor  proceeded  regularly  although  slowly. 
The  child  was  born  without  artificial  assistance."  Soon  after 
delivery  there  was  post-partum  haemorrhage  and  hour-glass  con- 
traction, and  the  placenta  was  removed  by  the  hand  introduced 
into  the  uterus.  In  two  hours  she  became  "sick  at  the  stomach, 
had  noises  in  her  ears,  became  talkative,  and  had  a  frequent  pulse. " 
In  another  hour  symptoms  of  pulmonary  thrombosis  occurred. 
Patient  died  in  a  few  minutes.  It  is  somewhat  difficult  to  realize 
that  this  tragedy  was  enacted  in  England,  the  land  where  the  mid- 
wifery forceps  were  invented. 

In  discussing  the  subject  of  protracted  labor,  I  shall  in  the  fiirt 
place  refer  only  to  those  cases  in  which  there  is  no  mechanicrl 
obstacle  to  delivery,  and  the  delay  in  the  expulsion  of  the  child 
is  due  to  certain  abnormalities  of  the  uterine  contractions.  A 
labor  has  been  unduly  prolonged  when  it  has  lasted  twenty-four 
374 


PROLONGED    LABOR  375 

hours  or  longer.  The  most  serious  protracted  labors  are  those 
in  which  the  second  stage  lasts  longer  than  four  hours.  The 
dangers  to  both  mother  and  child  increase  in  almost  geometrical 
progression  (doubled  each  hour)  as  the  hours  roll  on  beyond 
this  limit. 

Uterine  Inertia. — When  the  pains  are  weak  we  have  inertia  of 
the  uterus.  Herman  insists  on  the  importance  of  recognizing  two 
varieties : 

1.  Primary  uterine  inertia,  or  weak  uterine  action.  When 
the  pains  early  in  labor  are  weak  or  few.  Under  ordinary  circum- 
stances the  pains  become  more  frequent  and  stronger. 

2.  Secondary  uterine  inertia,  temporary  passiveness,  or  uterine 
exhaustion.  When  the  pains  early  in  labor  are  frequent  and  strong 
but  not  effective,  in  consequence  of  which  the  uterus  gets  tired 
and  the  pains  get  less  frequent  and  less  strong,  and  at  length  may 
cease  altogether. 

Tetanic  Contraction  of  the  Uterus. — Braxton  Hicks  first  clearly 
demonstrated  that  in  protracted  labor,  and  especially  in  obstructed 
labor,  the  intervals  between  the  pains  frequently  get  shorter  until 
at  last  there  is  no  interval  at  all,  and  the  uterus  is  continuously 
contracted — i.  e.,  there  is  tonic  or  tetanic  contraction  of  the  uterus. 

Differences. — Herman  also  insists  on  the  importance  of  making 
a  diagnosis  between  secondary  inertia  and  tonic  contraction  of 
the  uterus.  He  gives  the  points  of  difference  somewhat  as  follows: 
In  secondary  uterine  inertia  the  expression  is  placid,  pulse  not 
over  100,  the  breathing  not  hurried;  the  uterus  is  not  tender;  the 
child  can  be  moved  about;  the  presenting  part  can  be  pushed 
up  easily ;  there  is  little  or  no  swelling  of  vagina  and  vulva. 

In  tonic  contraction  of  the  uterus,  the  expression  of  face  is 
tired  and  anxious,  pulse  is  small  and  quick — 120  or  over — breath- 
ing hurried  ;  the  uterus  is  tender  and  hard;  child  can  not  be  moved 
about ;  the  presenting  part  can  not  be  pushed  up ;  there  is  swell- 
ing of  vagina  and  vulva  if  the  head  is  in  the  pelvic  cavity. 

These  differential  signs  of  the  two  conditions  are  correct  and 
important,  but  it  is  well  to  bear  in  mind  that  weak  uterine  con- 
tractions accompanied  with  little  or  no  pain,  if  continued  long 
enough,  are  generally,  if  not  always,  followed  by  tetanic  contrac- 
tion of  the  uterus  accompanied  by  intense  suffering.  A  certain 
amount  of  confusion  is  apt  to  arise  through  our  unscientific  method 
of  substituting  the  word  pains  for  uterine  contractions,  although 


376        PEOLONGED    AND    PKECIPITATE    LABOR 

for  clinical  purposes  it  is  often  convenient  to  do  so.  Further 
references  are  made  to  abnormal  contractions  in  connection  with 
' '  dry  ' '  labor, 

CAUSES  OP  PROLONGED  LABOR 

The  causes  of  prolonged  labor  are :  weak  constitution,  general 
exhaustion  from  debilitating  diseases,  hot  climate,  a  luxurious  life, 
indulgence,  etc.,  frequent  child-bearing,  undue  distention  of  the 
uterus  from  excess  of  liquor  amnii,  loaded  rectum,  distended  blad- 
der, mental  conditions,  such  as  depression,  fright,  etc.,  age  (labor 
often  tedious  in  elderly  primiparse),  undue  obliquity  of  the  uterus, 
early  rupture  of  membranes. 

In  many  cases  we  do  not  know  the  causes.  It  is  remarkable 
that  an  ordinarily  healthy  woman  may  in  one  instance  have  a 
rapid  labor  and  in  a  couple  of  years  after  have  a  tedious  labor 
without  any  known  cause.  While  it  is  unnecessary  to  pay  much 
attention  to  such  causes  as  weak  constitution,  hot  climate,  fre- 
quent child-bearing,  etc.,  one  should  keep  in  mind  others  of  the 
above-named  causes. 

Hydramnios. — Undue  distention  of  the  uterus  from  excess  of 
liquor  amnii  does  undoubtedly  tend  to  prevent  strong  uterine  con- 
tractions. Even  after  the  membranes  are  ruptured  the  head  of 
the  child  may  act  as  a  ball  valve  and  cause  retention  of  the 
greater  part  of  the  ''waters"  until  the  head  is  slightly  pushed 
up  by  the  fingers,  or  pushed  on  one  side  by  a  single  blade  of  the 
forceps. 

Adhesion  of  Membranes. — Unusually  firm  adhesions  of  the 
membranes  to  the  uterine  wall  may  prevent  the  "  bag  of  waters" 
from  bulging  into  the  os  and  stretching  it.  A  slight  detachment 
produced  by  passing  the  finger  within  the  os  and  sweeping  it  round 
will  frequently  induce  stronger  pains. 

Loaded  Rectum. — Fulness  of  the  rectum  may  cause  weakness 
of  pains  early  in  labor.  If,  however,  the  physician  carries  out  the 
directions  as  to  the  administration  of  an  enema  in  all  cases  of 
labor,  he  will  guard  against  this. 

Distended  Bladder. — Fulness  of  the  bladder  may  cause  weak- 
ness of  the  pains  in  two  ways :  (1)  by  causing  the  ' '  bearing  down  ' ' 
efforts  to  be  painful;  (2)  by  partial  obstruction  when  in  a  case 
of  cystocele  the  full  bladder  is  found  in  the  pelvis  in  front  of  the 
presenting  part  of  the  child. 


PROLONGED    LABOR  377 

Emotion,  as,  for  instance,  when  the  entrance  of  the  physician 
into  the  room  "  frightens  away  the  pains,"  is  a  well-known  cause  of 
temporary  weakness  of  pains. 

Age  in  certain  cases  tends  to  cause  prolonged  labor,  especially 
in  elderly  primipartc.  '  It  is  supposed  by  many  that  the  pains  are 
apt  to  be  irregular  in  the  very  young  and  thus  prolong  the  labor. 
This  is  not  in  accord  with  our  experience  in  the  Burnside,  where 
several  girls,  at  ages  from  thirteen  to  fifteen,  have  been  delivered, 
and  as  a  rule  have  shown  no  abnormality  in  this  regard. 

Deviation  of  the  Uterine  Axis. — Excessive  lateral  obliquity  is 
occasionally  a  cause  of  prolonged  labor.  Anteversion  with  more 
or  less  flexion  is  probably  a  more  frequent  cause.  On  account  of 
undue  laxity  of  the  abdominal  walls  the  fundus  may  hang  for- 
ward in  such  a  way  that  the  presenting  part  is  directed  backward 
toward  the  sacrum  instead  of  toward  the  pelvis. 

DRY  LABOR 

Dry  labor  occurs  when  membranes  are  ruptured  before  labor 
or  early  in  labor.  The  so-called  dry  labor  is  in  a  large  proportion 
of  cases  a  protracted  labor,  nearly  always  accompanied  by  serious 
symptoms  and  frequently  followed  by  disastrous  results,  as  in  the 
case  of  the  Princess  Charlotte. 

Definition  of  Term. — The  term  ''  dry,"  as  applied  to  such  labors, 
is  unscientific  and  to  a  certain  extent  misleading.  A  dry  labor  is 
one  in  which  the  membranes  are  ruptured  and  the  waters  evacu- 
ated before  the  onset  of  labor,  during  early  uterine  contractions  or 
during  the  first  stage  of  cervical  dilatation.  In  other  words,  the 
term  "  dry"  simply  refers  to  premature  rupture  of  the  membranes 
and  discharge  of  the  liquor  amnii.  If  any  portion  of  the  parturient 
canal  (especially  the  mucous  membrane  of  the  vagina)  becomes  hot 
and  dry,  that  condition  should  be  considered  as  one  of  the  com- 
plications, and  not  as  an  essential  feature  of  the  "  dry  ''  labor. 

Dangers. — The  dangers  to  the  mother  and  child  may  be  enu- 
merated as  follows : 

The  dangers  to  the  mother  are :  Exhaustion  from  long-contin- 
ued pains  with  tetanic  contraction  of  the  uterus,  rupture  of  the 
uterus,  laceration  of  the  cervix,  vagina,  pelvic  floor,  and  perinseum, 
various  forms  of  fistulae,  post-partum  haemorrhage,  pulmonary 
thrombosis,  septicaemia.  The  dangers  to  the  child  are  chiefly 
asphyxiation  and  meningeal  haemorrhage. 


378        PEOLONGED    AND    PEECIPITATE    LABOE 

Physiology. — In  connection  with  the  physiology  of  labor  refer- 
ence was  made  to  the  mechanism  of  uterine  expulsion.  While 
as  a  rule  every  muscle  in  the  body  has  an  opponent  the  mus- 
cular fibers  of  the  uterus  have  as  their  opponent  the  liquor 
amnii  contained  within  the  membranes,  acting  by  hydrostatic 
pressure. 

Premature  rupture  of  the  membranes  destroys  the  proper  equi- 
librium of  the  various  forces  in  a  way  not  easily  understood.  Gen- 
erally something  like  a  storm  arises,  accompanied  with  irregular 
contractions,  and  perhaps  tetanic  contraction  of  the  uterine  walls, 
spasms  of  the  cervix,  and  pains,  sometimes  intolerably  severe, 
with  diminished  expulsive  force. 

These  great  changes  in  the  expulsive  forces  have  much  more  to 
do  with  the  difficulties  connected  with  the  progress  of  the  labor 
than  the  shape  of  the  hard  presenting  part  as  compared  with  a  bag 
of  water. 

History  of  a  case  which  occurred  many  years  ago : 

Primipara.  Full  term.  Membranes  ruptured  Thursday  morning. 
Labor  pains  commenced  the  following  Sunday  morning.  The  contrac- 
tions soon  became  irregular  and  were  accompanied  by  intense  pain, 
amounting  to  agony  at  times.  Occiput  posterior.  Administered  chlo- 
roform. Introduced  hand  and  rotated  occiput  to  the  front.  Applied 
forceps,  delivered  with  difficulty.  Was  mortified  to  find  that  the  occiput 
had  slipped  to  the  rear  while  I  was  applying  the  blades  of  the  forceps, 
and  there  was  a  bad  rupture  of  the  perinseum  and  pelvic  floor. 

The  treatment  of  this  case  was,  in  many  respects,  anything  but 
good.  The  labor  occurred  at  a  time  when  I  had  rather  hazy  ideas 
as  to  the  proper  treatment  of  dry  labors.  In  the  first  place,  I  did 
not  take  sufficient  care  of  the  patient  during  the  two  days  interven- 
ing between  the  rupture  of  the  membranes  and  the  onset  of  labor. 
Next,  I  administered  chloroform  myself,  chiefly  from  a  desire  to 
save  my  patient  the  payment  of  an  extra  fee.  Next,  I  gave  chlo- 
roform badly.  Finally,  my  treatment  of  the  occipito-posterior 
position  was  faulty. 

There  was  no  nurse  present,  the  people  were  poor,  and  I  tried 
to  do  the  best  I  could  without  assistance.  In  recent  years  I  have 
not  attempted  anything  of  this  sort.  I  want  an  assistant  who  will 
give  all  his  attention  to  the  administration  of  the  anaesthetic. 
Fortunately,  in  this  case  the  mother  and  child  both  did  well,  and 


PROLONGED    LABOR  379 

I  was  able  to  repair  the  injuries  to  the  pelvic  floor  and  perinasiim  by 
immediate  operation. 

I  now  pass  on  to  speak  of  later  work,  giving  especially  the  re- 
sults of  my  observation  during  the  last  five  years.  Before  doing 
so,  however,  I  shall  return  to  the  case  of  the  Princess  Charlotte 
and  express  certain  opinions  from  a  clinical  standpoint. 

After  the  rupture  of  the  membranes  at  seven  o'clock  there  was 
a  pause,  followed  shortly  by  pains,  which  during  the  latter  part  of 
the  night  were  very  severe.  The  cervix  was  probably  dilated  at 
about  seven  o'clock  Tuesday  morning.  Patient  was  then  almost 
exhausted.  She  urgently  required  assistance,  and  should  have 
been  delivered  about  eight  or  nine  o'clock,  or  by  eleven  o'clock  at 
the  latest.  Pains  were  less  severe  during  Tuesday,  but  became 
strong  again  about  midnight.  Delivery  was  expected  every  hour 
during  the  first  half  of  Wednesday.  Child  died,  probably  during 
this  (Wednesday)  morning.  Uterine  contraction  strong,  with 
great  suffering  Wednesday  afternoon  and  evening.  Child  born  at 
nine  o'clock. 

The  chief  cause  of  the  delay  after  Tuesday  morning  was  prob- 
ably faulty  position  of  the  head,  the  occiput  being  posterior.  After 
delivery  the  patient  suffered  terribly  from  exhaustion  and  shock. 
There  was  hour-glass  contraction  and  considerable  haemorrhage. 
There  was  probably  serious  injury  to  the  pelvic  floor,  laceration  of 
the  cervix,  and  a  certain  amount  of  necrosis  of  the  tissues,  sub- 
jected to  the  prolonged  pressure,  which  would  have  resulted  in  a 
fistula,  or  two  or  three  fistulse,  had  the  patient  lived. 

General  Statements. — Before  going  into  details  the  following 
general  statements  may  be  made : 

A  small  proportion  of  dry  labor  cases  progress  favorably  even 
when  membranes  have  ruptured  two  to  seven  days  before  the 
onset  of  labor. 

Generally  the  labors  are  tedious  and  painful  far  beyond  the 
average. 

The  tremendous,  storms  which  sometimes  suddenly  and  unex- 
pectedly arise  in  connection  with  the  uterine  contractions  are 
occasionally  accompanied  by  pains  amounting  to  agony,  which  is 
unendurable  for  any  length  of  time. 

In  many  cases  where  the  patients'  lives  are  saved  much  in- 
jury is  done  through  haemorrhages  or  injuries  to  the  parturient 
canal. 


380        PEOLONGED    AND    PEECIPITATE    LABOE 

By  judicious  treatment  the  lives  of  mothers  and  children  can 
generally  be  saved,  and  the  sufferings  of  the  mother  can  be  greatly 
diminished. 

In  a  large  majority  of  cases  the  occiput  is  turned  to  the  rear,  and 
remains  so  unless  the  malposition  is  rectified  artificially. 

In  a  small  proportion  of  cases  of  these  occipito-posterior  posi- 
tions the  occiput  goes  to  the  front  naturally. 

In  a  certain  proportion  of  dry  labors  there  is  some  pelvic  de- 
formity, generally  contraction  of  the  brim, 

I  shall  now  refer  to  a  few  cases  illustrating  some  of  these  points. 

Malposition  of  Head. — I  had  noticed  years  ago  that  among  the 
many  varieties  and  complications  of  tedious  dry  labor,  malposi- 
tion of  the  head  was  somewhat  common.  I  have  recently,  how- 
ever, reached  a  definite  conclusion  that  in  the  majority  of  cases  of 
pronounced  dry  labor — that  is,  when  the  membranes  have  rup- 
tured before  the  onset  of  labor  (especially  some  time  before) — the 
occiput  points  to  the  rear.  Whether  this  faulty  head  position  is 
the  cause  or  effect  of  the  evacuation  of  the  liquor  amnii,  I  do  not 
know. 

In  the  early  part  of  1899  I  happened  to  have  three  difficult  dry 
labors  within  a  short  time,  two  of  them  being  the  worst  I  ever  saw. 
In  each  the  occiput  was  posterior.  I  then  went  over  some  of  my 
notes,  and  found  that  such  complication  was  more  common  than  I 
had  thought.  I  have  studied  the  matter  somewhat  carefully  since 
and  shall  give  some  statistics  later. 

Danger  from  Pain. — The  following  report  illustrates  the  great 
danger  which  sometimes  arises  from  the  extreme  pain : 

Primipara.  An  educated,  refined,  and  somewhat  delicate  and  small 
woman,  graduate  of  the  Toronto  General  Hospital  Training  School  for 
Nurses,  married  to  a  physician  living  in  Ontario.  Came  to  Toronto  for 
her  accouchement,  and  was  staying  at  the  house  of  a  friend  before  coming 
into  a  private  ward  at  the  Burnside.  The  membranes  ruptured  one 
morning,  without  warning,  and  she  at  once  went  to  the  hospital.  Walked 
about  a  great  deal  during  the  day  with  the  hope  of  bringing  on  labor  pains. 
The  following  day  she  did  more  walking  until  she  became  weary,  and  yet 
no  pains  appeared.  About  eight  in  the  evening  she  was  lying  on  a  couch, 
but  got  up  somewhat  hurriedly  and  went  into  the  next  room  to  look  for 
something  she  wanted.  She  was  then  seized  with  severe  pains.  Dr. 
Smith,  the  resident  interne,  and  Miss  McKellar  were  up-stairs  looking 
after  a  patient  suffering  from  post-partum  haemorrhage,  and  did  not  get 
down-stairs  to  our  patient  for  about  half  an  hour.     I  was  sent  for,  but 


PROLO^^GED    LABOK  381 

did  not  reach  the  hosi)ital  until  nearly  ten  o'clock.  I  found  the  patient 
exhausted,  and  suffering  so  terribly  that  I  feared  she  would  go  into  con- 
vulsions, notwithstanding  the  fact  that  some  chloroform  had  been  admin- 
istered. I  have  since  been  told  by  Miss  McKellar  that  she  never  before 
nor  since  saw  a  patient  suffer  such  agony  for  an  hour.  I  ordered  chloro- 
form to  be  administered  to  the  surgical  degree  as  rapidly  as  possible, 
while  I  was  ^jreparing.  I  introduced  first  fingers,  then  whole  hand, 
rotated  so  as  to  bring  occiput  to  the  front,  applied  the  forceps  and  de- 
livered, operation  being  completed  at  eleven  o'clock.  The  patient  made 
a  good  recovery. 

It  may  be  noticed  in  connection  with  this  report  that  great 
efforts  were  made  by  Miss  McKellar,  Dr.  Smith,  and  to  some  ex- 
tent myself,  to  get  the  woman  to  exert  herself  as  much  as  possible 
with  the  hope  of  hurrying  the  onset  of  labor  pains.  I  have  lately 
come  to  the  conclusion  that  such  efforts  are  decidedly  injurious. 
I  think  that  the  patient  should  keep  as  quiet  as  possible  and  gen- 
erally in  bed.  I  should  not  say  that  it  is  always  necessary  for  a 
woman  to  remain  constantly  in  bed,  especially  when  the  mem- 
branes rupture  many  days  before  labor  commences;  but  I  think 
that  she  should  keep  as  quiet  as  possible  and  not  do  anything  which 
is  likely  to  make  her  tired.  I  think  that,  in  this  instance,  the  ter- 
rible nerve  storm  which  attacked  this  delicate  little  woman  was  to 
some  extent  due  to  the  fact  that  she  was  partially  worn  out  before 
the  contractions  commenced. 

Kennedy  Mcllwraith's  case.  Primipara.  Membranes  ruptured  a 
week  before  labor.  After  onset  of  labor  pains  went  on  fairly  well.  Child 
expelled  normally  with  occiput  to  the  front.  The  labor  would  have  been 
quite  uneventful  except  for  the  accident  of  a  somewhat  bad  rupture  of  the 
perinseum,  which  was  restored  by  immediate  oiDeration.  I  mention  this 
case  simply  to  show  that  what  one  might  call  an  extreme  form  of  dry 
labor  may  occur  without  any  serious  complication. 

Primipara  at  Burnside.  Labor  forty  hours.  Liquor  amnii  discharged 
thirty  hours  before  delivery.  Occiput  posterior.  Under  an  anaesthetic, 
hand  introduced  into  the  vagina  and  unsuccessful  efforts  made  to  bring 
the  occiput  to  the  front.  Applied  the  forceps,  delivered,  occiput  remain- 
ing posterior.  I  may  say  that  I  think  the  patient  in  this  case  was  not 
well  managed,  and  would  not  be  treated  in  the  same  way  to-day.  She 
should  have  been  delivered  ten  hours  earlier,  instead  of  waiting  until  the 
soft  parts  were  fully  dilated  and  the  head  jammed  down  in  such  a  way 
that  rotation  was  impossible.  Chloroform  should  have  been  adminis- 
tered sooner,  the  parts  should  have  been  dilated  artificially,  malposition 
corrected,  and  the  child  delivered  by  forceps. 


382        PROLONGED    AND    PEECIPITATE    LABOE 

Positions. — Before  speaking  of  treatment  I  wish  to  refer  to  a 
few  points  in  connection  with  my  last  twenty-one  cases  of  dry 
labor.  In  eleven  there  were  difficult  occipito-posterior  positions; 
in  five  there  were  occipito-posterior  positions  with  natural  rotation 
of  occiput  to  the  front;  in  five  there  were  occipito-anterior  posi- 
tions. I  am  not  certain  as  to  the  exact  truth  in  the  last  two  sets 
of  cases — that  is,  the  cases  of  occipito-posterior  positions  which 
rotated  naturally  to  the  front,  and  the  ordinary  occipito-anterior 
cases.  There  must  generally,  or  frequently  at  least,  be  some 
doubt  whether  an  occipito-anterior  position  was  not  originally 
an  occipito-posterior.  By  external  examination  we  can  nearly 
always  discover  at  once  whether  the  occiput  points  to  the 
left  or  right,  but  we  can  not  always  decide  with  certainty  as  to 
whether  it  points  to  the  front  or  the  rear.  By  internal  exam- 
ination we  can  not  get  any  information  on  this  point  in  a  fairly 
large  proportion  of  cases  early  in  labor,  because  we  can  not  reach 
the  presenting  head. 

In  difficult  occipito-posterior  cases  the  occiput  was  rotated  to 
the  front  manually  in  seven  cases  and  kept  in  such  position  until 
the  forceps  were  applied.  The  occiput  was  manually  rotated  to 
the  front,  but  slipped  to  the  rear  again  while  the  forceps  were  being 
applied,  in  two  cases.  The  occiput  could  not  be  rotated  to  the 
front  without  too  much  violence  in  two  cases. 


TREATMENT    IN    DRY    LABOR 

Before  giving  definite  rules  as  to  treatment,  I  shall  make  a  few 
cHnical  remarks  regarding  the  following  two  cases: 

A.  B.  I  para.  Membranes  ruptured  at  9.30  a.  m.  Seen  by  me  10.45 
A.  M.  Patient  had  had  no  pains.  By  external  examination  the  back  of 
the  child  easily  discovered  on  mother's  right,  and  slightly  posterior. 
Within  a  few  minutes  I  was  able  to  make  the  following  diagnosis:  Dry 
labor,  head  presenting  in  .second  or  third  position.  By  internal  exami- 
nation I  could  make  out  absolutely  nothing  as  to  presentation. 

I  have  made  my  diagnosis,  in  part  at  least.  What  is  my  prognosis  ? 
The  condition  is  serious;  I  think  of  the  various  dangers  to  which  I  have 
alluded,  and  desire  to  avoid  them.  I  have  no  idea  that  I  can  make  the 
labor  easy,  but  I  feel  that  I  can  guard  against  most  of  the  dangers,  if  not 
all.  I  order  rest  and  quiet  as  much  as  possible.  The  patient  tells  me  she 
would  like  to  get  up  "to  look  after  a  few  little  things."  I  agree  at  once, 
largely  because  I  do  not  wish  to  lay  down  iron  rules  which  might  cause 


PEOLONGED    LABOR  383 

some  exaggerated  views  as  to  danger,  and  thus  cause  alarm  In  the  patient. 
At  the  same  time  I  tell  husband  and  nurse  I  want  none,  or  as  little  as 
possible,  of  that  "moving  about"  which  is  so  dear  to  some  midwives  and 
accoucheurs.  She  gets  up,  puts  on  a  wrapper,  looks  after  her  "few  little 
things"  and  returns  to  her  bed.  An  enema  is  then  administered. 
When  slight  pains  commence  at  1  p.  m.  three  doses  of  chloral  are  given 
at  intervals  of  twenty  minutes,  and  appear  to  afford  some  relief.  At 
3  p.  M.  some  dilatation  of  the  os,  occiput  to  the  right  posterior.  At  5  p.  m. 
a  little  chloroform  dm-ing  j^ains,  occiput  apparently  coming  to  the  front, 
uterine  contractions  accompanied  by  severe  pains.  At  6  p.  m.  chloroform 
almost  to  surgical  degree  ;  occiput  found  to  be  anterior,  os  fairly  well 
dilated.  Chloroform  to  obstetrical  degree  another  hour.  At  7  p.  m. 
chloroform  to  surgical  degree,  forceps  apiDlied,  easy  delivery.  Placenta 
separated  in  about  fifteen  minutes,  expressed  in  twenty  minutes.  Un- 
eventful recovery. 

In  this  case  it  appeared  to  me  that  the  rest,  the  chloral,  and  the 
chloroform  all  did  good.  In  addition,  I  think  the  strong  regular 
uterine  contractions  between  3  and  6  o'clock  were  sufficient  to 
cause  normal  flexion,  and,  as  a  consequence,  anterior  rotation  of 
the  occiput.  Probably  expulsion  would  soon  have  occurred  with- 
out the  application  of  the  forceps,  but  we  thought  the  patient  had 
suffered  enough. 

Strong  and  regular  pains  may  come  on  even  a  week  after  rup- 
ture of  membranes,  as  in  the  case  of  Mcllwraith  already  mentioned, 
and  cause  anterior  rotation  of  the  occiput  and  normal  expulsion. 

C.  D.  Ill  para.  Pains  commenced  at  midnight,  membranes  prob- 
ably ruptured  in  about  half  an  hour.  Saw  patient  first  at  1.45  a.  m. 
Nurse  gave  her  a  hot  bath  and  enema.  The  patient  was  then  kept  quiet 
in  bed. 

Contractions  became  fairly  strong  about  three  o'clock,  but  were  irreg- 
ular and  accompanied  by  much  suffering.  At  3.30  and  3.45  chloral  given 
in  fifteen  grain  doses.  After  4,  pains  were  exceedingly  severe,  with  very 
short  intermissions.  The  chloral  had  done  absolutely  no  good.  What 
should  one  do  now  ?  Would  it  be  well  to  keep  the  patient  again  in  a  hot 
bath  and  then  give  her  a  hot  douche,  for  instance,  a  solution  of  lysol,  for 
some  fifteen  or  twenty  minutes  ?  No.  Under  such  circumstances  the 
hot  bath  and  the  hot  douche  are  absolutely  worthless ;  the  storm  is  coming 
on  and  will  soon  be  in  full  force  unless  one  acts  promptly  and  \'igorously. 
At  5.30  chloroform  given  to  the  surgical  degree  by  Dr.  Hutchinson. 
Chloroform  had  a  marked  influence  on  cervix,  vagina  and  perinaeum. 
Parts  were  dilated  by  hand.  In  a  few  minutes  forceps  applied  ;  easy 
delivery.  Mother  and  child  both  did  well. 
26 


884        PEOLONGED    AND    PEECIPITATE    LABOR 

Definite  Directions  as  to  Treatment. — Put  the  patient  in  a  hot 
bath  and  administer  an  enema.  These  procedures  should  be  car- 
ried out  as  a  matter  of  routine  in  all  cases  of  labor.  Keep  the 
patient  quiet  in  bed.  Give  chloral  in  all  cases  of  dry  labor  as  soon 
as  the  pains  commence.  In  those  cases  where  the  membranes  rup- 
ture days  before  the  onset  of  labor  it  may  be  well  to  give  two  or 
three  doses  of  chloral  about  bedtime.  As  directed  years  ago  by 
Playfair,  give  fifteen  grains  every  fifteen  or  twenty  minutes  for 
three  doses. 

Give  chloroform  to  the  obstetrical  degree  when  the  pains  be- 
come very  severe.  It  is  not  easy  to  give  any  definite  rule  as  to 
how  much  chloroform  should  be  administered  in  such  cases.  We 
must  always  bear  in  mind  the  fact  that  the  administration  of  large 
quantities  of  chloroform  may  be  followed  by  very  serious  results, 
especially  by  post-partum  haemorrhage.  Having  this  in  view  we 
ought  to  be  exceedingly  careful  about  the  administration  of  chloro- 
form early  in  the  first  stage,  or  perhaps  at  any  time  in  the  first  stage. 

If  a  patient  when  first  seen  has  been  in  dry  labor  for  many  hours 
and  is  considerably  exhausted,  and  there  is  at  the  same  time  spasm 
of  the  cervix  or  Bandl's  ring,  or  of  the  whole  body  of  the  uterus, 
chloroform  may  be  administered  as  follows :  Administer  chloroform 
to  the  surgical  degree  perhaps  for  twenty  minutes.  The  patient 
may  shortly  afterward  waken,  feel  much  refreshed,  and  the  spasm 
may  be  greatly  or  wholly  relieved.  In  other  cases  it  may  be  well 
to  give  chloroform  for  a  short  time,  followed  by  hypodermic  in- 
jection of  morphine,  allowing  the  patient  to  have  a  comfortable 
sleep,  after  which  the  condition  will  be  found  to  be  greatly  im- 
proved. 

Make  it  a  rule  always  to  terminate  labor  as  soon  as  possible, 
under  such  circumstances,  even  when  there  is  considerable  rigidity 
of  the  perinseum,  vagina,  and  cervix.  As  before  mentioned,  the 
administration  of  chloroform  nearly  always  makes  a  vast  differ- 
ence, the  parts  become,  if  not  dilated,  much  more  dilatable  than 
they  were. 

It  is  generally  desirable  to  rotate  the  occiput  to  the  front,  but 
the  treatment  of  occipito-posterior  cases  is  discussed  in  detail  in 
another  section. 

The  Use  of  Oxytocic  Drugs. — Ergot,  as  before  mentioned,  is 
always  likely  to  do  harm,  and  is  especially  dangerous  in  cases  of 
prolonged  labor,  whether  "  dry  "  or  otherwise. 


PROLONrxED    LABOR  385 

Quinine  is  worthy  of  consideration.  When  given  in  a  full  dose 
of  ten  grains  it  occasionally  has  a  good  effect. 

Strychnine  is  valuable  in  certain  cases  of  uterine  inertia  accom- 
panied with  general  constitutional  weakness. 

DIFFICULT  OCCIPITO-POSTERIOR  POSITIONS 
Confusion  of  Opinions. — Nothing  in  connection  with  obstetrics 
is  more  confusing  than  the  literature  respecting  occijnto-posterior 
l)ositions.  The  following  are  the  chief  reasons  for  such  confusion : 
1.  In  the  vast  majority  of  such  positions  the  occiput  easily  rotates 
to  the  front  as  soon  as  the  first-coming  part  of  the  head  reaches  the 
pelvic  fioor.  2.  On  account  of  this  fact  many  prefer  non-interfer- 
ence in  all  cases  excepting  when  it  becomes  actually  necessary. 
3.  Others  interfere,  as  a  rule,  and  think  their  interference  has  been 
effective,  without  considering  Nature's  work. 

Proper  flexion  of  the  head  causes  the  occiput  to  strike  the  floor 
of  the  pelvis  first.  The  resistance  of  the  latter  forces  the  occiput 
to  the  front.  It  is  generally  accepted  as  a  sort  of  obstetrical  tru- 
ism that  failure  of  anterior  rotation  in  such  cases  is  always  due  to 
insufficient  flexion. 

Groups. — Herman  goes  a  little  farther  and  gives  good  clinical 
points.  He  considers  that  occipito-posterior  cases  are  divided 
into  two  groups : 

1.  Bregmato-Cotijloid — when  the  head  is  well  flexed  so  that 
the  anterior  fontanelle  or  bregma  lies  opposite  the  acetabulum. 
This  is  the  favorable  and  more  common  variety  in  which  the  occi- 
put always  comes  to  the  front. 

2,  Fronto-Cotyloid — when  the  head  is  not  well  flexed,  and  as  a 
consequence  the  frontal  eminence  instead  of  the  anterior  fontanelle 
lies  opposite  the  acetabulum.  This  is  the  unfavorable  and  less 
common  variety,  in  which  the  occiput  does  not  generally  come  to 
the  front. 

Reasons  for  Imperfect  Flexion. — The  reasons  given  for  imper- 
fect flexion  are  often  ingenious  according  to  our  conception  of  the 
laws  of  physics,  but  are  generally  purely  theoretical  and  do  not 
help  us  much  practically. 

Reference  has  been  made  to  the  loss  of  equilibrium  or  proper 
relationship  between  the  expelling  and  resisting  forces  as  a  cause 
of  tedious  ' '  dry  "  labor.  Following  similar  lines  we  may  designate 
the  causes  of  insufficient  flexion  as  follows:  1.  Weak  uterine  con- 


386        PEOLONGED    AND    PRECIPITATE    LABOE 

tractions.  2.  Irregular  uterine  contractions.  3.  Tetanic  uter- 
ine contractions. 

Weak  uterine  contractions  generally  lead  to  erratic  uterine  con- 
tractions or  tetanic  contraction  of  the  uterus,  if  labor  is  much  pro- 
tracted. 

Diagnosis. — Abdominal  Examination.  This  examination  should 
be  carried  out  according  to  methods  already  described.  If  move- 
ments of  the  "  small  parts  "  (foetal  limbs)  are  felt  in  front,  either 
on  right  or  left  side  of  patient's  abdomen,  the  child's  belly  looks  to 
the  front.  When  the  movements  of  the  foetal  limbs  are  felt  to- 
ward the  left  front  the  back  and  occiput  of  the  child  point  toward 
the  right  rear.  The  back  may  also  be  felt  easily  in  this  position. 
It  is  learned  by  the  "  fundal  grip  "  that  the  breech  is  at  the  fundus. 
There  is,  therefore,  a  right  occiput  posterior  position.  If,  on  the 
other  hand,  the  small  parts  are  felt  moving  in  front  but  on  right 
side,  and  the  back  of  the  child  on  the  left  and  slightly  to  rear,  there 
is  a  left  occipito-posterior  position. 

Vaginal  Examination.  One  should  also  examine  carefully  by 
the  vagina.  Contrary  to  the  rule  in  normal  labor,  frequent  vaginal 
examinations  are  generally  necessary  in  order  to  obtain  an  exact 
knowledge  of  the  position  of  the  head  at  all  stages.  Early  in  labor 
the  small  or  posterior  fontanelle  points  to  either  the  right  or  left 
sacro-iliac  joint.  The  large  or  anterior  fontanelle  can  be  felt  more 
or  less  easily.  This  in  itself  should  make  one  suspect  the  occipito- 
posterior  position.  The  posterior  fontanelle  should  always  be 
within  reach  if  favorable  progress  is  being  made.  As  the  head 
advances  the  large  fontanelle  should  become  more  difficult  to 
reach.  If,  on  the  other  hand,  the  large  fontanelle  becomes  more 
easy  to  reach,  extension  instead  of  flexion  is  taking  place  and  the 
occiput  is  likely  to  rotate  to  the  hollow  of  the  sacrum,  instead  of 
rotating  to  the  front  as  described  in  connection  with  the  mechan- 
ism of  labor.  We  have  thus  produced  what  is  called  persistent 
or  difficult  occipito-posterior  or  face  to  pubes  position.  It  may  be 
that  Berry  Hart  is  correct  in  saying  that  no  part  in  the  pelvis  ro- 
tates primarily  backward ;  but  from  a  clinical  standpoint  it  is  con- 
venient to  have  in  our  minds  the  backward  rotation  of  the  occiput 
rather  than  the  forward  movement  of  the  forehead.  In  some 
cases  the  ear  of  the  babe  forms  a  good  guide,  as  the  pinna  and 
lobule  pass  from  the  side  of  the  head  toward  the  occiput.  Intro- 
duce the  finger,  or  fingers,  into  the  vagina  alongside  of  head  until 


PROLOXGED    LABOR  387 

the  ear  is  reached.  If  the  lobule  points  to  the  front  the  occiput  is 
anterior;  if  to  the  back,  it  is  posterior.  It  is  generally  easier  to 
feel  the  anterior  ear.  Pass  the  finger  or  fingers  toward  the  front 
in  searching  for  the  ear. 

TREATMENT 

Having  in  view  the  causes  of  the  failure  of  anterior  occiput 
rotation,  we  divide  these  cases  into  two  classes : 

1.  Those  in  which  the  pains  are  strong. 

2.  Those  in  which  the  pains  are  weak  or  irregular. 

In  the  first  class  no  treatment  is  necessary  as  a  rule.  The 
normal  uterine  contractions  pushing  the  head  against  the  ordinary 
resisting  forces  produce  proper  flexion,  with  resulting  anterior  rota- 
tion of  the  occiput  and  normal  expulsion.  These  regular  and 
effective  contractions  may  commence  days  after  the  rupture  of  the 
membranes  and  result  in  normal  expulsion,  as  already  mentioned. 

In  the  second  class  early  interference  is  always  advisable,  if  not 
actually  necessary.  In  the  early  part  of  the  first  stage  pursue  the 
same  line  of  treatment  which  was  recommended  for  dry  labor — i.  e., 
give  chloral,  morphine,  or  chloroform  according  to  indications. 

General  Rules  as  to  Procedure  when  the  Pains  are  Weak  or 
Irregular. — Rotate  the  occiput  and  the  back  of  the  body  toward  the 
front  in  the  latter  part  of  the  first  or  very  early  in  the  second  stage. 

If  the  head  and  shoulders  of  the  child  are  rotated  so  as  to  bring 
the  occiput  and  back  to  the  front,  they  will,  as  a  rule,  remain  in 
that  position. 

If  the  occiput  is  turned  to  the  front  without  rotation  of  the 
shoulders,  the  head  will,  as  a  rule,  rotate  back  to  its  posterior  posi- 
tion after  withdrawal  of  the  hand. 

If  one  is  able  to  turn  the  occiput  to  the  front,  but  fails  to  rotate 
the  shoulders,  he  should  apply  forceps,  or  at  least  one  blade,  before 
the  withdrawal  of  the  hand. 

Sometimes  after  correcting  the  malposition  Nature  is  able  to 
complete  delivery,  but  this  is  not  usual  in  the  cases  requiring  such 
interference  on  account  of  the  abnormal  character  of  the  pains. 
Delivery  by  forceps  is  generally  advisable.  At  the  same  time  great 
care  is  required  when  there  is  secondary  inertia,  as  before  pointed 
out.  One  should  not,  however,  make  the  mistake  of  depending 
on  quinine,  strychnia,  ergot,  or  stimulants,  or  any  combination  of 
these,  and  leaving  the  patient  undelivered  for  hours  after  the  parts 


388        PEOLONGED    AKD    PEECIPITATE    LABOE 

are  dilated.  Exaggerated  apprehension  respecting  the  dangers  of 
post-partum  haemorrhage  as  the  result  of  delivery  during  uterine 
inertia  has  resulted  in  sad  consequences  in  many  a  tedious  labor. 

Rotation  of  Head  and  Shoulders. — Let  an  assistant  anaesthetize 
the  patient  to  the  surgical  degree.  We  shall  suppose  that  we  have 
the  most  common  variety — the  occiput  pointing  to  the  right  rear. 
By  abdominal  palpation  we  find  back  of  child  on  the  right  side  and 
more  or  less  posterior.  The  left  shoulder  of  the  child  is  in  front 
but  on  right  side  of  mother's  abdomen.  By  vaginal  examina- 
tion the  small  fontanelle  is  found  near  the  right  sacro-iliac  joint. 
The  large  fontanelle  is  found  near  the  os  uteri — generally  easily 
accessible. 

Place  patient  in  lithotomy  position  across  the  bed.  Introduce 
right  hand  into  vagina  and  put  left  hand  over  the  abdomen  close 
to  but  outside  the  anterior  shoulder  of  the  child. ^  Grasp  the 
head  between  the  thumb  and  four  fingers  of  the  right  hand  and, 
during  an  interval  between  pains,  turn  the  occiput  forward. 
Sometimes  it  is  impossible  to  rotate  the  head  until  it  is  pushed 
upward  to  some  extent.  It  may  be  necessary  to  push  it  above  the 
brim.  In  certain  cases  the  head  is  impacted  in  the  pelvis  so  firmly 
that  it  can  neither  be  rotated  nor  pushed  upward.  This  is  likely 
to  happen  only  when  interference  has  been  too  long  delayed. 
At  the  same  time,  with  the  left  hand  on  the  abdomen,  push  the 
anterior  shoulder  toward  the  mother's  left  side. 

I  have  found,  in  a  somewhat  large  proportion  of  cases,  that  it 
was  impossible  for  me  to  push  the  shoulder  over  to  the  other  side 
of  the  abdomen  by  external  pressure.  Especially  is  this  the  case 
when  there  is  tetanic  contraction  of  the  uterus.  When  I  am  unable 
to  do  any  satisfactory  work  with  the  external  hand  I  frequently 
pass  the  right  hand  beyond  the  head  and  rotate  the  shoulder  with 
the  hand  in  the  uterus. 

Grandin  and  Jarmin  depend  on  internal  manipulation  alone  in 
all  cases,  and  recommend  us  to  introduce  the  hand  and  grasp  the 
foetus  (they  do  not  say  how  or  where,  but  I  presume  they  grasp  the 
body  in  any  way  they  can)  and  rotate  in  its  long  axis  until  the  occi- 
put is  anterior.  Some  of  our  English  friends  object  strongly  to 
this  procedure,  because  they  consider  it  both  unnecessary  and 
dangerous. 

1  Mcllwraith  introduces  his  left  hand  into  vagina  and  puts  the  right  hand 
on  the  abdomen. 


PEOLONGED    LABOR  389 

It  is  always  well,  however,  to  try  the  conjoined  manipulation 
first ;  but  in  case  of  failure  by  this  method,  try  at  once  to  rotate  the 
shoulders  with  the  internal  hand.  Many  of  those  who  deliver  with 
the  woman  on  her  side  prefer  to  introduce  left  hand  into  vagina  and 
place  the  right  hand  oyer  the  abdomen. 

As  before  pointed  out  in  connection  with  dry  labor,  in  which  we 
have  such  a  large  proportion  of  difficult  occipito-posterior  posi- 
tions, it  is  often  necessary  to  commence  our  manipulations  before 
the  parts  are  properly  dilated.  Endeavor  to  do  so  before  the 
uterine  inertia  gives  place  to  tetanic  spasm.  Definite  rules  can 
scarcely  be  given,  but  one  should  always  keep  in  view  the  advisa- 
bility of  interference,  which  should  be  undertaken  too  early  rather 
than  too  late.  If  one  waits  until  the  completion  of  the  first  stage 
— i.  e.,  until  the  parts  are  dilated — he  will  often  be  too  late. 

The  history  of  manual  rotation  of  occipito-posterior  cases  in 
Toronto  is  somewhat  interesting.  Many  years  ago  Hodder,  the 
elder  Ross,  Uzziel  Ogden,  and  others,  were  much  influenced  by  the 
teachings  of  Smellie,  Leroux,  Meigs,  and  Hodge,  and  made  various 
endeavors  to  effect  rotation  by  the  fingers  or  hand.  Algernon 
Temple,  Macdonald,  Baines,  the  younger  Ross,  Chas.  J.  Hastings, 
Mcllwraith,  and  others,  including  myself,  now  in  active  practice, 
worked  on  similar  lines,  and  nearly  all  at  the  present  time  rotate 
the  head  in  the  w^ay  I  have  described  when  we  consider  interfer- 
ence necessary.  How  far  we  agree  as  to  when  interference  is 
actually  necessary  I  can  not  say. 

Many,  if  not  the  majority,  of  British  obstetricians  do  not  con- 
sider this  manual  rotation  either  a  scientific  or  practical  method; 
many  of  them  do  not  even  think  it  possible.  Herman,  however, 
recommends  the  combined  external  and  internal  methods  which 
have  been  described,  but  does  not  favor  the  internal  manipula- 
tion alone. 

Other  Methods  of  Rotation. — Forceps.  A  brief  reference  may 
be  made  to  other  methods  of  rotation.  Some  use  the  forceps  for 
the  purpose.  I  have  had  no  experience  in  this  procedure,  which  I 
consider  much  less  effective  and  much  more  dangerous  than  manual 
rotation. 

Flexion. — This  is  considered  the  scientific  method  of  treatment. 
Posterior  occiput  rotation  is  due  to  want  of  flexion.  We  are 
asked  to  treat  the  cause.  Produce  flexion  by  pushing  up  the 
forehead  or  by  firm  resistance  of  fingers  directed  toward  the  fore- 


390        PEOLONGED    AND    PEECIPITATE    LABOR 

head  during  a  pain.  Or  produce  flexion  by  bringing  down  the 
occiput  by  means  of  the  fingers  or  by  a  vectis.  So  far  as  my  ex- 
perience goes  these  methods  are  useless. 

Delivery  by  Forceps. — The  application  of  the  forceps  is  quite 
justifiable  in  some  cases.  This  is  true  especially  when  one  first 
sees  the  patient  late  in  labor  and  finds  so  much  swelling  that  he 
can  not  feel  the  sutures  and  fontanelles.  (Try  the  ear  touch, 
however,  in  such  cases.)  The  forceps  are  also  indicated  when  one 
is  unable  to  rotate,  as,  for  instance,  in  case  of  extreme  tetanic 
contraction  and  when  the  head  is  impacted  in  the  pelvis.  Milne 
Murray  considers  that  the  forceps  are  indicated  when  the  occiput 
remains  posterior  during  descent,  and  when  anterior  rotation  be- 
gins, but  is  checked  at  such  a  stage  as  to  leave  the  head  impacted 
in  the  transverse  diameter  of  the  cavity.  He  also  says,  in  com- 
paring manual  rotation  with  the  use  of  the  forceps,  that  he  has 
given  the  method  (manual  rotation)  a  careful  trial  in  many  cases 
of  occipito-posterior,  and  has  come  to  the  conclusion  that  the 
cases  in  which  it  seems  to  be  effective  are  just  those  cases  in  which 
the  occiput  would  have  come  forward  if  left  alone.  Why,  after 
careful  trial,  an  obstetrician  so  skilled  fails  to  accomplish  in  diffi- 
cult cases  what  we  in  Toronto  undoubtedly  do  frequently  with 
comparative  ease,  I  can  not  explain.  The  application  of  the  for- 
ceps with  the  ordinary  pelvic  curve  high  up  is  somewha.t  dangerous, 
because  the  blades  grasp  the  head  in  such  a  way  as  to  undo  flexion 
during  traction  and  are  also  apt  to  slip.  On  the  other  hand,  with 
the  straight  forceps  it  is  difficult  to  apply  the  blades  in  such  a  way 
that  they  will  not  slip  off  during  traction.  Murray  uses  special 
forceps,  with  the  curves  much  flattened,  for  these  cases.  A  prelim- 
inary application  of  the  forceps  reversed  while  the  head  is  fairly 
high  has  been  recommended.  After  slight  traction  on  the  occiput 
the  forceps  are  withdrawn  and  reapplied  in  the  ordinary  way. 

Extraction  by  forceps  in  the  ordinary  way  is  not  uncommon 
in  the  Rotunda,  Dublin.  When  anterior  rotation  of  the  occiput 
takes  place  the  forceps  are  removed  and  reapplied.  If  the  occipito- 
posterior  position  persists,  the  handles  of  the  forceps  are  carried 
well  forward  over  the  mother's  abdomen  until  the  occiput  is  born, 
and  then  in  the  opposite  direction  as  the  face  passes  beneath  the 
pubic  arch. 

Postural  Treatment. — We  are  told  by  some  that  the  woman 
ought  to  be  placed  on  the  side  to  which  the  front  of  the  child  looks. 


PEOLONGED    LABOR  391 

Thus,  in  the  position  which  we  have  been  considering — i.  e.,  occiput 
right  posterior — the  woman  should  he  on  her  left  side.  I  shall 
make  no  objection  to  this,  although  I  do  not  know  that  it  accom- 
plishes much.  We  are  told  by  others  that  the  woman  ought  to 
be  placed  in  the  genupectoral  position  and  retained  there  as  long 
as  her  strength  permits.  I  consider  this  a  useless  species  of  cruelty 
which  is  never  justifiable. 

Preventive  Treatment. — I  mention  preventive  treatment  now, 
although  it  should  generally  come  first.  Herman  recommends 
the  following  treatment  when  the  diagnosis  is  made  before  rupture 
of  the  membranes.  When  the  occiput  is  right  posterior,  put  the 
hands  on  abdomen,  the  right  behind  the  child's  anterior  shoulder, 
the  left  in  front  of  the  posterior  shoulder,  then  by  a  number  of 
movements  push  the  anterior  shoulder  toward  the  left  and  the 
posterior  shoulder  toward  the  right  side.  The  back  of  the  child 
is  thus  brought  to  the  front  if  there  is  sufficient  liquor  amnii. 
Then  leave  the  labor  to  take  its  natural  course. 

I  have  sometimes  employed  this  method.  In  one  case,  occiput 
right  posterior,  I  pushed  the  child's  back  toward  mother's  front. 
The  child's  body  was  turned  so  easily  that  the  back  went  past  the 
median  line  before  I  noticed  it,  and  I  feared  that  I  was  converting 
an  occiput  right  posterior  to  a  left  posterior.  After  further  manip- 
ulation the  head  became  engaged  in  the  pelvis,  the  occiput  to  the 
left  front.  Then  labor  proceeded  normally  and  child  was  delivered 
without  further  interference. 

It  is  difficult  to  push  the  back  exactly  the  right  distance, 
and  it  is  possible  to  undo  flexion  or  displace  an  arm  by  such 
manipulation.  If  the  pains  are  fairly  strong,  as  before  stated, 
these  cases  nearly  always  progress  favorably  when  the  patient 
is  left  alone.  I  think  in  the  great  majority  of  such  cases 
Nature  can  do  her  work  better  without  the  interference  of  the 
physician. 

In  conclusion,  the  following  rules  for  treatment  are  recom- 
mended : 

1 .  When  the  pains  are  strong  and  regular  do  not  interfere,  but 
leave  the  case  to  Nature. 

2.  When  the  pains  are  weak  or  irregular  or  both,  interfere  as 
soon  as  possible. 

3.  When  the  occiput  can  not  be  rotated  to  the  front  by  manip- 
ulation, apply  the  axis  traction  forceps  and  extract,  carrying  the 


392        PEOLONGED    AND    PEECIPITATE    LABOE 

handles  well  forward  until  the  occiput  is  delivered  and  then  back- 
ward as  the  face  passes  beneath  the  pubic  arch. 

LABOR  OBSTRUCTED  BY  FAULTY  CONDITIONS  OF  THE 
SOFT  PARTS 

Cervix, — Rigidity  of  the  cervix  is  a  somewhat  frequent  cause 
of  partial  obstruction  to  labor.  The  rigidity  may  be  due  to  spasm, 
or  to  hypertrophic  elongation,  or  to  inflammatory  induration,  or 
to  apparent  atresia  (conglutinatio  orificii  externi),  or  to  cicatricial 
stenosis.  The  most  common  of  these  is  spasm  of  the  external  os. 
There  is  sometimes  rigidity  of  the  internal  os,  which  is  called  by 
some  trismus  uteri.  It  is  said  that  there  occasionally  exists  a 
contraction  of  Bandl's  ring,  but  such  contraction  without  general 
tetanic  contraction  above  the  ring  must  be  exceedingly  rare. 

Treatment.  Administer  chloroform  to  the  surgical  degree,  as 
recommended  for  rigidity  of  cervix  in  dry  labor,  and  dilate  with 
the  fingers.  Crucial  incisions  have  been  recommended,  but  I  have 
never  found  them  necessary.  Generally  the  cervix  is  easily  dilated 
when  the  patient  is  fully  anaesthetized.  If  this  can  not  be  accom- 
plished in  the  way  described,  there  is  generally  some  very  serious 
condition  requiring  ah  abdominal  section.  Certain  hydrostatic 
dilators  were  used  for  dilating  the  rigid  cervix,  especially  a  few 
years  ago,  but  many  obstetricians  have  found  them  unsatisfactory. 

The  administration  of  chloral,  as  before  recommended,  fre- 
quently produces  an  excellent  effect.  Some  apply  a  solution  of 
cocaine  to  the  cervix.  Mcllwraith  has  found  this  very  satisfactory 
in  certain  cases.  He  soaks  a  pledget  of  absorbent  cotton  in  a 
5  per  cent,  solution  of  cocaine,  and  places  this  over  the  cervix 
(preferably  introducing  it  through  a  speculum).  Garrigues  recom- 
mends a  rectal  suppository  containing  cocaine  gr.  ss. 

The  hot  vaginal  douche  is  quite  commonly  used  to  overcome 
rigidity  of  the  cervix,  but  I  have  never  found  it  accomplish  much. 
It  was  formerly  the  custom  on  the  part  of  many  to  apply  the 
forceps  after  partial  dilatation  and  to  use  traction  to  complete  the 
dilatation.  In  unskilled  hands  this  is  a  very  difficult  operation, 
and  under  any  circumstances  is,  I  think,  not  so  safe  and  satis- 
factory as  manual  dilatation.  Reference  is  also  made  to  this  in 
the  chapter  on  The  Forceps. 

Abnormalities  of  Vagina  and  Perinseum. — These  may  cause 
obstruction  to  labor.     The  most  common  are  congenital  malfor- 


PROLONGED    LABOR  393 

mations  of  vagina,  incomplete  vaginal  atresia  caused  by  acci- 
dental complications,  the  results  of  disease  or  tears  in  former 
labors,  neoplasms  of  the  vagina,  cicatrices  of  perineum,  and 
tetanic  contraction  of  the  levator  ani  muscle.  In  cases  of  spasm 
of  this  muscle  a  tense  ridge  can  be  felt  on  each  side  of  the  vagina 
about  an  inch  from  the  vulva. 

Treatment.  The  treatment  of  these  various  abnormal  condi- 
tions is  to  a  large  extent  similar  to  that  proposed  for  rigidity  of 
the  cervix.  Depend  chiefly  on  chloroform  anaesthesia  and  manual 
dilatation.  Sometimes  cicatrices  should  be  incised.  Partial  vaginal 
atresia  due  to  inflammations  or  diseases,  such  as  diphtheria,  small- 
pox, and  syphilis,  may  constitute  an  insurmountable  obstacle  to 
delivery  in  the  ordinary  way  and  render  coeliotomy  necessary. 

Dystocia  from  Conditions  due  to  Operations  for  Retroflexion 
of  the  Uterus. — Ventro-fixation  sometimes  causes  serious  symp- 
toms and  dystocia  during  a  succeeding  pregnancy  and  labor. 
When  the  fundus  has  become  adherent  to  the  abdominal  wall  the 
anterior  uterine  wall  can  not  expand  as  pregnancy  advances.  As 
a  consequence  there  is  considerable  distortion  of  the  uterus.  The 
cervix  is  generally  dragged  upward  to  such  an  extent  that  it  can 
scarcely  be  reached  by  ordinary  digital  examination.  The  patient 
suffers  much  during  the  latter  part  of  pregnancy.  During  labor 
the  bag  of  waters  is  pushed  down  toward  the  front  wall  of  the 
uterus  and  not  toward  the  os.  As  a  result  dilatation  of  the  cer- 
vix does  not  take  place  without  artificial  assistance,  and  tetanic 
contraction  and  rupture  of  the  uterus  may  ensue. 

Vagino-fixation  is  probably  even  worse  than  ventro-fixation. 
In  ventro-fixation  the  fundus  is  firmly  stitched  to  the  fascia  and 
perhaps  also  to  the  muscles  of  the  abdominal  wall.  In  vagino- 
fixation the  fundus  is  stitched  to  the  anterior  vaginal  wall.  This 
causes  still  greater  distortion,  suffering,  and  difficulty  in  pregnancy 
and  labor. 

Obstetricians  and  gynaecologists  now  generally  agree  that 
neither  of  these  operations  should  be  performed  during  the  child- 
bearing  period;  also  that  suspension  of  the  uterus  is  quite  safe 
and  justifiable.  In  suspension  the  uterus  is  simply  attached  to 
the  peritonaeum  in  such  a  way  that  two  new  peritoneal  ligaments 
are  formed  which  help  to  hold  the  fundus  in  proper  position. 

Treatvient.  It  is  generally  necessary  to  assist  cervical  dilata- 
tion manually,  the  patient  being  anaesthetized.     Dilate  the  vagina 


394        PEOLONGED    AND    PRECIPITATE    LABOE 

and  introduce  the  hand  and  dilate  the  cervix  with  finger  or  fingers. 
It  may  be  necessary  to  introduce  the  whole  hand  into  vagina  and 
to  dilate  cervix  with  thumb  and  fingers.  Sometimes,  especially 
after  vagino-fixation,  Caesarean  section  must  be  performed. 

Ovarian  Tumors. — Reference  has  already  been  made  to  the 
presence  of  abdominal  tumors  before  and  during  pregnancy,  and 
especially  to  fibro-myomata  of  the  uterus.  The  presence  of  an 
ovarian  tumor  is  a  very  serious  comphcation  of  pregnancy  and 
labor.  Frequently,  probably  in  the  majority  of  cases,  the  diag- 
nosis is  not  made  before  the  onset  of  labor.  In  quite  a  large  pro- 
portion of  cases  the  tumor  is  the  slow-growing  dermoid. 

Treatment.  When  discovered  during  pregnancy  the  tumor 
should  be  removed  by  laparotomy.  When  first  discovered  during 
labor  removal  by  operation  is  now  generally  recommended.  After 
removal  of  the  tumor,  suture  the  abdominal  wound,  allow  the  labor 
to  go  on  in  the  ordinary  way,  but  apply  the  forceps  as  soon  as 
possible.  Some  prefer  a  Caesarean  section  immediately  after 
ovariotomy  rather  than  allow  the  patient  to  go  through  labor 
after  a  severe  operation.  If  the  tumor  is  in  such  a  position 
that  it  does  not  interfere  with  labor,  or  if  it  can  be  easily 
pushed  out  of  the  way,  an  operation  may  not  be  necessary.  Any 
extended  efforts  at  reposition,  or  any  such  procedures  as  tap- 
ping, as  formerly  recommended  and  practised,  are  now  generally 
forbidden. 

After  spontaneous  labor  without  operation  the  patient  is  still 
exposed  to  danger,  especially  peritonitis  following  gangrene  of  the 
tumor  from  pressure  during  the  passage  of  the  child.  The  patient 
should  be  carefully  watched  during  the  puerperium.  If  untoward 
symptoms  arise  from  injury  to  the  tumor,  operative  interference 
is  urgently  required.  In  any  case  the  tumor  should  be  removed 
as  soon  as  possible  after  labor. 

Other  Abdominal  Tmnors. — Tumors  of  various  abdominal 
organs,  such  as  kidneys,  spleen,  liver,  pancreas,  omentum,  etc., 
may  cause  dystocia.  No  definite  rules  can  be  laid  down  as  to 
treatment.  Surgical  interference,  such  as  removal  of  the  tumor 
or  Caesarean  section,  may  be  necessary.  In  other  cases  version 
or  the  application  of  the  forceps  may  be  sufficient. 

Vaginal  and  Vulvar  Tumors. — Tumors  originating  in  the  vagi- 
nal wall  are  rare.  Occasionally  cysts  require  puncture,  and  tumors 
such  as  fibroids  or  cancer  require  removal.     Tumors  starting  from 


PROLONGED    LABOR  395 

other  organs  are  not  uncommon,  as,  for  instance,  polypus  of  the 
cervix  uteri.     Celiotomy,  etc.,  may  be  necessary. 

Distended  Bladder. — Retention  of  urine  should  be  relieved  by 
catheterization.  It  is  sometimes  difficult  to  pass  a  catheter.  The 
meatus  is  often  displaced  forward  and  the  urethra  lengthened  by 
stretching.  Instead  of  the  ordinary  female  catheter,  which  is  too 
short,  and  the  soft-rubber  catheter,  which  is  too  flexible,  it  may 
be  necessary  to  use  a  male  metal  catheter.  One  made  of  soft 
metal  which  can  be  bent  is  the  best  kind  to  use. 

Cystocele  is  a  prolapse  of  the  posterior  wall  of  the  bladder  with 
the  anterior  wall  of  the  vagina.  It  sometimes  projects  through 
the  vulva,  and  has  been  incised  in  mistake  for  a  bag  of  waters.  It 
may  be  detected  by  digital  examination.  The  fingers  can  be 
passed  behind  but  not  in  front  of  the  projection.  The  most  cer- 
tain test  is  the  passage  of  a  sound  or  catheter  through  the  urethra 
into  the  cystocele.  There  are  two  dangers  arising  from  cystocele : 
first,  obstruction  to  labor ;  second,  sloughing  of  part  carried  down 
in  front  of  head  and  subjected  to  pressure. 

Treatment.  Draw  off  the  urine  with  a  catheter  and  push  up 
the  tumor  if  necessary,  or  puncture  the  cystocele. 

Calculus  in  the  Bladder. — A  stone  in  the  bladder  has  been 
known  to  cause  dystocia  during  labor. 

Treatment.  Push  the  stone  above  the  brim,  if  possible.  If  this 
can  not  be  done,  dilate  the  urethra  and  extract  the  stone.  If  the 
stone  can  not  be  thus  extracted,  perform  a  vaginal  cystotomy  in 
preference  to  crushing,  which  involves  danger  to  the  soft  parts. 

Rectocele. — Occasionally  there  is  prolapse  of  the  posterior  wall 
of  the  vagina  with  anterior  wall  of  the  rectum.  In  such  a  case  we 
may  find  it  projecting  from  the  vulva.  It  is  possible  also  for  a  coil 
of  intestine  to  come  down  in  Douglas's  pouch  and  project  exter- 
nally, being  covered  only  by  the  vaginal  wall.  An  accumulation 
of  large,  hard  scybala  may  obstruct  labor. 

Treatment.  Inject  a  couple  of  ounces  of  warm  sweet  oil  or 
glycerine,  break  down  the  mass  and  scoop  it  out. 

Carcinoma  of  the  Rectum. — This  does  not  frequently  interfere 
with  the  passage  of  the  child.  When  it  is  likely  to  do  so,  Csesarean 
section  should  be  performed  or  labor  should  be  induced  if  the  child 
is  alive.  In  a  patient  seen  with  Dr.  McPhedran  and  Mr.  Cameron 
fourteen  years  ago  in  the  Toronto  General  Hospital,  we  decided  to 
induce   premature  labor.     This  was  accomplished  without  any 


396         PEOLONGED    AND    PRECIPITATE    LABOR 

difficulty,  and  mother  and  child  went  out  of  the  hospital  alive  two 
weeks  later. 

Hasmatoma  or  Thrombus  of  the  Vagina  or  Vulva. — This  is  a 
collection  of  blood  in  the  submucous  tissue  of  the  vagina  low  down 
or  in  the  connective  tissue  of  the  vulva  generally  confined  to  one 
side,  due  to  rupture  of  veins.  It  frequently  commences  close  to 
the  vaginal  outlet  on  one  side  and  extends  thence  up  the  vagina 
and  outward  toward  the  labium.  Occasionally  it  is  a  cause  of 
obstruction  to  labor.  It  is  said  to  occur  only  once  in  2,000  or 
3,000  labors. 

I  saw  with  Dr.  Jas.  M.  Macallum,  in  1888,  a  patient  who  had  a 
vaginal  thrombus  which  was  ruptured  during  labor.  There  was 
slight  haemorrhage  following  the  rupture,  but  the  descent  of  the 
head  soon  stopped  it.  After  the  birth  of  the  child  there  was  an 
alarming  recurrence  of  the  haemorrhage,  which  we  finally  stopped 
by  pressure  by  means  of  a  vaginal  tampon  and  a  pad  over  vulva 
kept  in  position  by  a  T  bandage.  The  late  Dr.  Muir,  of  Truro, 
N.  S.,  reported  a  similar  case  shortly  before. 

In  1890  a  patient  in  the  Burnside  went  through  labor  without 
any  untoward  symptoms  and  without  interference.  During  the 
night  there  was  much  pain  in  the  vulva,  and  we  found  on  the  fol- 
lowing day  a  large  swelling  in  the  right  labium  majus,  which  was 
still  causing  great  pain.  An  incision  was  made  in  a  line  parallel  to 
the  long  axis  of  the  body,  the  clot  (larger  than  a  cricket  ball)  was 
removed,  the  bleeding  was  easily  controlled  by  pressure  with  an 
antiseptic  pad,  and  the  wound  was  quite  healed  in  a  few  days. 

A  thrombus  of  this  sort  may  be  formed  some  time  after  labor. 
A  few  months  ago  a  primipara,  aged  thirty-five,  had  a  normal 
labor.  Puerperium  normal  for  three  weeks.  On  twenty-second 
day  after  labor  went  for  a  short  drive  in  an  easy  carriage.  During 
the  same  evening  was  seized  with  pain  in  left  side  of  vulva.  Pain 
shortly  extended  to  rectum.  On  the  following  morning  I  found 
swelling  in  left  side  rather  deeply  seated  and  pressing  slightly  on 
rectum.  Pain  relieved  for  a  few  nights  with  opium  suppositories. 
At  the  end  of  a  week  the  swelling  was  smaller,  and  entirely  dis- 
appeared in  about  a  month. 

It  is  supposed  that  varicose  veins  predispose  to  haematoma. 
It  happens,  however,  that  in  the  four  cases  which  have  come  under 
my  own  observation  varicose  veins  preexisted  in  only  one  instance. 
The  smaller  blood  tumors  in  the  vulva  or  vagina  are  frequently 


PRECIPITATE    LABOR  397 

absorbed.  The  large  ones  generally  require  treatment  by  simple 
incision  and  pressure  to  stop  hiemorrhage,  as  mentioned  in  the  case 
of  the  Burnside  patient.  When  there  is  no  interference  the  tumor 
may  rupture  at  any  time  with  serious  or  even  fatal  haemorrhage, 
or  suppuration  may  occur  and  the  symptoms  of  septicaemia. 

Treatment.  It  is  better  not  to  interfere  with  small  thrombi. 
The  application  of  the  ice-bag  or  ice-water  coil,  as  recommended 
by  some,  is  likely  to  do  more  harm  than  good.  Every  thrombus 
in  this  region  which  causes  severe  pain  should  be  incised.  If  pain 
develops  in  a  thrombus,  no  matter  how  small,  it  should  be  incised 
before  suppuration  occurs,  if  possible.  The  blood  clots  should  be 
thoroughly  cleared  out,  and  the  bleeding  stopped  by  sutures  or 
pressure,  or  both.  Some  obstetricians  advise  the  packing  of  the 
cavity  with  iodoform  gauze.  One  may,  however,  find  no  cavity 
in  the  vulva  even  after  the  removal  of  a  large  mass  of  clots. 
There  is  so  much  elasticity  in  the  tissues  that  the  cavity  that 
contained  the  thrombus  disappears  very  rapidly  after  the  removal 
of  the  latter. 

(Edema  of  the  Vulva  is  not  uncommonly  so  great  as  to  interfere 
with  labor.  In  some  cases  the  passage  of  the  child  injures  the 
oedematous  tissues. 

Treatment.  Try  pressure  with  an  antiseptic  pad  and  T  band- 
age. If  this  is  not  sufficient,  make  numerous  punctures  in  the 
oedematous  tissue. 

Carcinoma  and  Sarcoma  of  the  Uterus  are  sometimes  discov- 
ered during  pregnancy  or  labor.  Of  these,  the  more  important 
from  an  obstetric  standpoint  is  the  carcinoma,  which  is  very  apt  to 
attack  the  cervix  and  obstruct  labor. 

Treatment.  Perform  hysterectomy,  or  induce  premature  labor, 
or  perform  Caesarian  section. 


PRECIPITATE  LABOR 

Precipitate  Labor  is  worthy  of  consideration  on  account  of  the 
risk  of  certain  accidents  to  mother  and  child.  Very  strong  uter- 
ine contractions  may  cause  the  expulsion  of  the  child  before  the 
mother  can  reach  her  bed.  In  connection  with  normal  labor,  refer- 
ence was  made  to  cases  in  which  the  child  was  expelled  while  the 
mother  was  at  stool.  The  child  may  be  born  when  the  mother  is 
standing  upright.    The  chief  dangers  to  the  mother  are  lacerations 


398         PROLONGED    AND    PRECIPITATE    LABOR 

of  the  cervix,  vagina,  pelvic  floor,  or  perinseum,  or  even  rupture 
of  the  uterus.  The  child  may  be  injured  by  falling  into  the  pan 
of  the  water-closet  or  on  to  the  floor.  The  cord  may  be  torn,  but 
the  laceration  thus  violently  produced  is  not  generally  accompanied 
by  profuse  haemorrhage.  Cases  are  reported,  however,  in  which 
fatal  haemorrhage  has  occurred  after  such  a  laceration.  Some- 
times such  rapid  expulsion  of  the  child  is  not  followed  by  strong 
uterine  contractions.  Excessive  post-partum  haemorrhage  under 
such  circumstances  is  rare. 

Treatment. — Chloroform   may  be    administered,   and  unduly 
rapid  expulsion  may  be  prevented  by  counter  pressure. 


CHAPTER  XVIII 

MALPRESENTATIONS  AND  ABNORMAL  CONDITIONS    OF 
THE   F(ETUS 


MALPRESENTATIONS 

Shoulder,  Arm,  and  Transverse  Presentations. — In  these  pres- 
entations the  long  axis  of  the  fcetus  does  not  correspond  with  that 
of  the  uterine  cavity,  but 
lies  obliquely  or  transversely. 
After  rupture  of  the  mem- 
branes the  arm  is  sometimes 
prolapsed  and  thus  becomes 
the  presenting  part.  The 
shoulder,  abdomen,  back,  or 
any  part  of  the  trunk  may 
present.  These  presentations 
occur  about  once  in  200  cases. 

Causes.  These  may  be 
briefly  enumerated :  1 ,  Im- 
maturity of  foetus;  2,  the 
death  or  maceration  of  the 
foetus;  3,  a  contracted  pel- 
vis, especially  in  conjugate 
diameter;  4,  spinal  deform- 
ity ;  5,  hydramnios ;  6,  laxity 
of  the  uterine  muscle. 

Varieties.  There  are  two 
varieties,  of  which  the  first 

is  the  more  common:    1,   dorso-anterior,    and   2,  abdomino-an- 
terior.     In  either,  the  head  may  be  on  the  right  or  the  left  side. 

Prognosis.  The  prognosis  is  unfavorable  to  both  mother  and 
child,  the  mortality  being,  for  the  mother,  1  in  9,  for  the  child 
1  in  2. 

Diagnosis.     By  abdominal  palpation.     The  size  of  the  uterus 
27  399 


Fig.  132. — Diagram  Illustrating  Locked 
Twins.     (American  Text-Book.) 


400      ABNORMAL    CO?^DITIONS    OF    THE    FCETUS 


is  increased  transversely.  The  head  is  generally  felt  in  one  iliac 
fossa,  and  the  breech  in  the  opposite  flank  generally  higher  up, 
while  a  resisting  plane  connects  the  two.  Nothing  can  be  de- 
tected before  labor  by  digital 
vaginal  examination  because 
the  presenting  part  is  high. 
The  bag  of  waters  is  unusu- 
ally large  and  long.  After  labor 
commences  the  shoulders  may 
be  felt. 

Note. — The  hand  may  de- 
scend with  the  head  or  breech. 
To  diagnose  which  hand  this  is, 
apply  your  right  hand  to  the 
hand  of  the  child,  and  if  your 
palm  corresponds  with  palm  of 
the  child  it  will  be  right,  if  not 
it  will  be  left.  A  right  hand 
means  right  shoulder,  etc. 

Terminations.  There  are 
several  terminations  possible : 
1.  Spontaneous  version.  The 
head  or  breech  is  substituted 
for  the  shoulder  by  uterine 
contractions  and  a  molding 
process  by  which  the  uterine 
cavity  becomes  ovoid  and  the 
long  axis  of  the  child  becomes 
vertical.  2.  Spontaneous  evolution.  The  head  is  fixed  above 
the  pubic  joint,  and  the  neck  jammed  against  the  pubes.  The 
anterior  shoulder  is  fixed  at  the  subpubic  ligament.  The  thorax 
is  driven  down  below  the  shoulder  and  the  body  becomes  doubled 
on  itself.  The  breech  is  forced  into  the  hollow  of  the  sacrum 
and  then  lower  until  it  is  expelled.  The  legs  follow  the  breech, 
the  thorax  follows  the  legs,  and  the  head  is  expelled  last.  3.  Evo- 
lution with  doubled  body.  The  fcetus  may  be  delivered  doubled 
(rare).  Results  in  neglected  cases  (usual)  are  very  serious.  The 
membranes  rupture  and  the  liquor  amnii  drains  away.  The  uterus 
contracts  and  may  rupture.  The  foetus  dies.  The  patient  sinks 
from  exhaustion  or  septicaemia. 


Fig.  133. — Fcetus  with  Ascites. 
(Tor.  Univ.  Museum.) 


MALPRESEXTATIOXS 


401 


Treatment.  Version,  either  cephalic  or  podalic,  may  be  per- 
formed either  by  external,  combined  external  and  internal,  or 
internal  manipulation.  As  a  last  resort,  decapitation  or  some 
other  form  of  embryotomy,  or  abdominal  section,  should  be  done. 

Complex  Presentations. — When  more  than  one  part  of  the 
f(rtal  body  i)resents,  it  is  spoken  of  as  a  complex  presenta- 
tion— e.  g.,  a  hand  with  a  head,  a  foot  with  the  head,  or  a  hand 
with  a  foot. 

Treatment.  When  a  hand  presents  with  the  head  there  are  four 
methods  of  procedure.     1.  Push  up  the  hand,  if  possible,  and  keep 


Fig.  134. — Axencephaltjs  with  Meningocele  and  Spina  Bifida. 


it  up  until  the  head  is  engaged  in  the  pelvis.  2.  Perform  version. 
3.  Deliver  with  forceps.  4.  Leave  the  case  to  nature.  When  a 
foot  presents  with  the  head,  push  up  the  foot,  if  possible,  or  pull 
down  the  foot  and  push  up  the  head,  producing  a  pelvic  presen- 


402      ABNOEMAL    CONDITIONS    OF    THE    FCETUS 


tation.  When  a  hand  and  foot  present,  push  up  the  hand,  but 
depend  mainly  on  pulhng  down  the  foot  and  converting  the  pres- 
entation into  a  breech. 

Dorsal  Displacement  of  the  Arm. — This  term  is  used  when  the 
arm  is  so  displaced  that  the  forearm  lies  transversely  across  and 

behind  the  neck.  It  is 
called  by  Barnes  the 
nuchal  hitching  of  the 
arm.  It  is  very  difficult 
to  diagnose,  not  gener- 
ally being  discovered  un- 
til the  forceps  have  been 
applied  and  failed  to  de- 
liver. 

Treatment.  Three 
courses  are  left  open:  1. 
Perform  version  under 
chloroform.  2.  Bring 
down  the  arm  over  the 
side  of  the  head,  convert- 
ing it  into  a  presentation 
of  the  head  and  arm.  3. 
Push  the  head  above  the 
brim  and  rotate  in  the 
direction  of  the  child's 
fingers  so  as  to  unwind  the 
arm  from  the  neck. 

Prolapse  of  Umbilical 
Cord. — The  accident  may 
happen  when  there  is:  1. 
An  excess  of  liquor  amnii, 
2.  A  premature  rupture 
of  the  membranes.  3. 
An  abnormal  presentation.  4.  An  abnormal  condition  of  the 
cord,  such  as  great  weight,  length,  etc. 

It  is  easy  to  diagnose  from  hand  or  foot  by  shape,  pulsa- 
tion, etc.  The  chief  danger  is  that  the  cord  may  be  compressed 
during  delivery  and  the  pressure  stop  hsematosis,  and  cause  as- 
phyxia— similar  to  suffocation  or  pulmonary  embolism  in  extra- 
uterine life. 


Fig.  135. — Double  Placenta. 
(Tor.  Univ.  Museum.) 


ABNORMALITIES 


403 


Treatment.  Three  methods  of  treatment  are  advised.  1.  Re- 
place the  cord.  This  may  be  accompUshcd  in  three  ways:  (a)  The 
fingers  carrying  it  up  and  retaining  it  until  the  head  has  descended, 
the  woman  being  in  semiprone  position,  {h)  By  repositor,  the  sim- 
plest kind  being  made  from  a  gum-elastic  catheter.  Make  a  hole 
opposite  the  eye,  pass  a  loop  of  tape  through  both  holes ;  secure  a 
loop  of  cord  in  the  loop  of 
tape,  but  do  not  pull  too 
tightly ;  pass  the  catheter 
into  the  uterus  with  the 
help  of  a  stylet;  withdraw 
the  stylet  and  leave  the 
catheter,  (c)  By  posture. 
Place  the  woman  in  the 
knee-chest  or  semiprone 
position.  2.  Apply  forceps. 
^.  Turn  after  membranes 
are  ruptured. 

ABNORMALITIES 

Locked  Twins.  —  These 
may  be  divided  into  four 
varieties.  1.  Both  heads 
may  present,  the  first  head 
descend  into  the  pelvis  and 
the  second  entering  the 
brim  may  get  jammed 
against  the  thorax  of  the 
first  child.  When  this  oc- 
curs one  head  should  be 
pushed  out  of  the  way  if  pos- 
sible, and  by  applying  for- 
ceps the  other  head  should 
be  engaged   in  the   pelvis. 

2.  A    foot  or  a  hand 
head  of  the  other.      Here, 
may  be,  should  be  pushed 
engage. 

3.  The  feet  of  the  twins 


Fig.    136. — Battledore     Placenta    (Mar- 
ginal Insertion  of  the  Cord). 

Maternal  surface  of  the  placenta,  and  chorion 
below  with  edge  of  membranes  on  left  side 
inverted  showing  a  small   portion   of  the 


of   one    child   may    present   with   the 

the  foot  or  the  hand,  as   the   case 

out  of  the  way  to  allow  the  head  to 

may  present  together;  then  one  child 


404      ABNOEMAL    CONDITIONS    OF    THE    FCETUS 

should  be  disengaged  as  rapidly  as  possible  and  the  other  one 
pulled  down. 

4.  The  heads  may  lock;  that  is,  the  first  child  may  come  out 


Fig.  137. — Battledore  Placenta  (Marginal  Insertion  of  the  Cord). 

Fcetal  surface,  with  a  portion  of  the  membranes  hanging  from  lower  edge  having 
the  gUstening  amnion  on  the  left  side;  a  portion  of  the  amnion  has  been  re- 
moved on  the  riglit  side,  below,  showing  the  fcetal  side  of  the  chorion. 

feet  first  and  be  delivered  as  far  as  the  head,  which  is  thus  found  to 
to  be  locked  with  the  head  of  the  second  child. 

Treatment.  In  such  cases  there  are  four  different  lines  of  treat- 
ment, (a)  The  heads  may  be  disentangled  and  the  second  pushed 
out  of  the  way  so  as  to  allow  the  first  to  engage,  (h)  The  forceps 


ABNORMALITIES 


405 


may  be  applied  to  the  head  of  the  second  child,  which  is  then 
dragged  past  the  body  of  the  first,  (r)  The  first  child  may  be  de- 
capitated, the  second  child  being  then  easily  expelled,  leaving  the 
first  head  to  come  last,  (c?)  The  lower  head  may  be  perforated  and 
extracted  with  the  cephalotribe,  or  some  other  means,  when  the 
other  child  will  be  easily  delivered. 

Double  Monsters. — These  may  be  divided  into  four  varieties 
(Playfair) : 

1.  Thoracopagus — i.  e.,  the  two  bodies  are  distinct  and  sepa- 
rate except  where  they  are  united  in  front,  to  a  varying  extent, 
by  the  thorax  or  abdomen.  This  is  the  most  common  of  these  con- 
ditions. In  a  large  proportion  of  these  both  children  present  by 
the  feet,  the  most  favorable  presentation.  Both  bodies  go  through 
the  pelvis  parallel  with  each  other,  the  posterior  head  entering  the 
pelvis  in  advance  of  the  anterior.     The  bodies  should  be  pulled 


Fig.  138. — Placenta,  Insertion  Velamintosa  (Lusk). 

well  forward,  especially  that  with  the  posterior  head,  to  which,  if 
necessary,  forceps  should  be  applied.  In  some  cases  perforation  of 
the  posterior  head  is  necessary.  When  both  heads  present,  one  is 
generally  born  first,  then  the  two  bodies  by  a  sort  of  spontaneous 
evglution,  and  lastly  the  second  head.     This  evolution  should  be 


406      ABNOEMAL    CONDITIONS    OF    THE    FCETUS 

assisted  as  much  as  possible.     It  may  be  necessary  to  divide  the 
band  of  union  or  perform  embryotomy. 

2.  Ischiopagus — i.  e.,  the  nearly  separate  bodies  are  united 
back  to  back  by  the  sacrum  and  lower  part  of  the  spinal  column. 
The  children  are  generally  expelled,  the  first  head,  then  the  bodies 
by  evolution,  then  the  second  head. 

3.  Dicephalous  monsters — i.  e.,  the  bodies  are  united  but  the 
heads  are  separate.  The  mechanism  of  delivery  is  usually  the 
same  as  in  class  2. 

4.  Cephalopagus — i.  e.,  the  bodies  are  separate,  but  the  heads 
are  partially  united.  This  condition  is  very  rare  and  the  delivery 
difficult,  embryotomy  being  usually  required. 

Intra-Uterine  Hydrocephalus. — This  condition  is  dangerous  to 
both  the  child  and  the  mother,  sixteen  out  of  seventy-four  mothers 
(Keiller)  having  rupture  of  the  uterus.  It  is  a  condition  seldom 
diagnosed  before  delivery.     The  head  is  large  and  round;  the 


Fig.  139. — Exomphalos. 

sutures  and  fontanelles  are  very  wide.  If  the  ordinary  methods 
fail  and  the  head  is  too  large  to  be  delivered  in  any  other  way, 
it  should  be  punctured. 

Dropsy  of  the  Foetus. — This  is  a  condition  where  there  is  fluid 
in  the  thorax  or  abdomen  of  the  child.  It  should  be  tapped. 
(Fig.  183.) 

Acardiac  Monster  (see  p.  186.)  This  does  not  usually  cause 
dystocia. 


ABNORMALITIES  407 

Anencephalus. — This  is  a  monster  possessing  a  trunk  and  an 
imperfectly  developed  head,  a  large  proportion  of  the  brain  and 
skull  being  absent.      On  account  of  the  absence  of  the  cranial 

vault,  the  face  appears  to  be  especially  prominent  and  the  eyes  pro- 


FiG.  140. — Pregnancy  advanced  Five  Months. 
Cord  twice  around  the  neck  and  once  around  the  arm.      (Tor.  Univ.  Museum.) 

trude.  The  neck  is  short  and  the  shoulders  comparatively  broad, 
which  latter  may  cause  serious  dystocia;  cerebral  meningocele 
and  spina  bifida  are  often  associated  with  it.     (Fig.  134.) 

Large  Foetus. — The  foetus  may  be  especially  large  and  the  skull 
ossified.  Forceps  or  version  should  be  tried.  If  these  fail,  a 
laparotomy  should  be  done.  If  this  is  impossible,  perforation  is 
indicated;  evisceration  is  sometimes  required  where  the  body  is 
very  large. 

Anomalies  of  the  Placenta. — There  are  several  anomaUes  of  the 
placenta.  There  may  be  multiple  (double,  etc.)  placenta,  and  also 
small  accessory  portions  of  the  placenta,  "placentse  succentu- 
riatse."     The  cord  may  be  attached  to  the  margin  of  the  placenta 


408      ABNOEMAL    CONDITIONS    OF    THE    FCETUS 

— "battledore  placenta";  or  the  vessels  of  the  cord  may  travel 
some  distance  through  the  membranes  before  reaching  the  pla- 
centa— "  inserta  velamentosa."  The  placenta  may  be  abnormally 
situated.  It  may  be  over  the  orifice  of  a  Fallopian  tube ;  over  or 
near  the  os  internum  (placenta  prsevia) ;  or  in  the  abdominal 
cavity  in  extra-uterine  or  ectopic  gestation.  There  may  be  in- 
farcts in  the  placenta,  the  red  infarct  being  known  as  apoplexy  of 


Fig.  141. — Anencephalus  with  Meningocele. 

the  placenta.  There  may  be  oedema  of  the  placenta,  a  condition 
usually  associated  with  hydramnion;  or  a  placentitis,  although 
some  deny  the  existence  of  the  latter.  There  may  be  degenera- 
tion of  the  placenta,  fatty,  calcareous,  pigmentary,  or  cystic,  or 
perhaps  syphilitic  disease. 

Anomalies  of  the  Umbilical  Cord. — Its  normal  length  is  about 
twenty  inches,  but  it  may  be  abnormally  long  or  short.  There  may 
be  torsion  or  rotation,  especially  in  the  seventh  month,  until  the 
vessels   are  partially  or   completely   closed,     The   cord  may  be 


ABNOKMALITIES 


409 


knotted.  There  may  be  a  hernia  of  some  of  the  abdominal  viscera 
of  the  foetus  at  the  insertion  of  the  cord.  The  cord  may  coil 
around  the  foetus;  it  may  b(^- 
come  cystic,  or  its  vessels  may  be- 
come stenosed  from  poriphlel)itis. 

Diseases  of  the  Foetus. — Dis- 
eases may  be  transmitted  by  the 
mother,  as  in  cases  of  lead  or 
other  diffusible  poisons,  eruptive 
fevers,  malaria,  syphilis,  and  tu- 
berculosis ;  or  it  may  be  a  dis- 
ease of  the  foetus  alone,  the 
mother  being  perfectly  healthy, 
such  as  peritonitis,  ascites  (rare), 
hydrocephalus,  meningocele, 
spina  bifida,  intra-uterine  ampu- 
tations, and  injuries  caused  by 
falls,  etc.,  of  the  mother. 

Death  of  the  Foetus.— The 
death  of  the  foetus  may  result 
from  disease  of  the  mother,  the 
placenta,  or  the  foetus  itself.  This 
event  is  diagnosed  by  the  absence 
of  the  foetal  movements  which 
have  previously  been  noticed, 
and  by  the  ordinary  auscultation 
signs.  There  is  a  progressive  re- 
duction in  the  size  of  the  moth- 
er's abdomen,  and  a  deteriora- 
tion of  her  health.  When  the 
foetus  dies  it  may  be  expelled 
soon,  or  it  may  be  retained  for 
some  time  ("missed  labor"). 
When  retained,  it  may  be  dis- 
solved in  the    liquor    amnii,    if 

death  occurs  at  an  early  period  of  pregnancy;  it  may  shrivel  or 
mummify ;  it  may  be  macerated ;  or  it  may  become  putrid.  It  is 
now  generally  supposed  that  "  missed  labor  "  with  long  retention 
of  the  child  occurs  only  in  extra-uterine  pregnancy  or  pregnancy 
in  one  horn  of  the  uterus  bicornis. 


Fig.  142.  —  Maceration  of  Dead 
fcettjs  retained  for  some  time 
IN  Uterus  with  Membranes  Un- 
ruptured. 

Non-putrefactive  softening  with  des- 
quamation of  the  epidermis  result- 
ing from  the  action  of  the  liquor 
amnii. 


CHAPTER  XIX 

ABNORMAL  CONDITIONS  OF   THE   UTERUS,  ITS  CONTENTS, 
AND   THE  MAMMARY  GLANDS 

ABNORMAL  CONDITIONS  OF  THE  UTERUS 

Rupture  of  the  Uterus. — There  are  two  degrees :  Complete,  in- 
volving the  muscular  tissue  and  peritonseum ;  incomplete,  involv- 
ing the  muscular  tissue  alone.  The  rupture  nearly  always  begins 
in  the  lower  segment  of  the  uterus,  which  is  abnormally  stretched. 
It  is  more  common  in  multipara  and  in  women  over  thirty. 

Several  causes  may  give  rise  to  rupture  of  the  uterus:  1.  Ob- 
structed delivery  from  contracted  pelvis,  transverse  presentation, 
hydrocephahc  head,  or  pelvic  tumors.  2.  Degeneration  of  the 
muscular  tissue  of  the  uterus.  3.  A  weak  cicatrix  after  a  former 
Csesarean  section.  4.  Violence  in  using  the  forceps  or  turning, 
tetanic  action  of  retracted  muscular  tissue,  as  from  early  admin- 
istration of  ergot. 

There  are  always  some  premonitory  signs  to  warn  the  obstet- 
rician of  the  approaching  danger.  The  ring  of  Bandl  rises  more 
than  1^  inches  above  the  symphysis.  The  temperature  rises  to 
above  101°  F.,  and  the  pulse  increases  in  frequency  above  110. 
The  uterus  becomes  tonically  contracted,  and  the  round  liga- 
ments stand  out  and  become  very  tense. 

Rupture  may  be  sudden  or  gradual,  the  latter  being  more  fre- 
quent. In  sudden  rupture  severe  and  continuous  pain  replaces 
the  rhythmical  uterine  pains.  In  addition  there  is  a  sudden  sharp 
pain,  sometimes  accompanied  with  a  snapping  noise,  which  pre- 
cedes the  continuous  pain.  The  respirations  become  hurried  and 
symptoms  of  shock  and  collapse  appear.  The  child  gradually 
recedes  to  some  extent  and  may  even  be  forced  into  the  peritoneal 
cavity,  although  this  seldom  occurs.  Such  recession,  with  mobil- 
ity of  a  presenting  part  previously  fixed,  sudden  pain  and  collapse, 
indicate  with  almost  absolute  certainty  rupture  of  the  uterus. 
The  symptoms  of  gradual  rupture  are  not  nearly  so  clearly  de- 
fined as  those  of  sudden  rupture,  but  resemble  them  to  a  certain 
410 


ABNOEMAL    CONDITIONS    OF    THE    UTERUS     411 

extent.     The  condition  may  not  be  recognized  until   the  hand  is 
introduced  into  the  uterus  to  remove  the  placenta. 

Treatment.  In  some  cases  when  rupture  is  threatened  it  may 
be  prevented.  An  anaesthetic  should  be  administered  if  the  pains 
are  very  severe  or  the  patient  is  becoming  exhausted;  the  child 
should  be  delivered  as  quickly  as  possible  by  forceps,  version, 


Fig.  143. — Rupture  of  Vagina.      (Tor.  Univ.  Museum.) 

etc.  If  it  is  possible  with  safety  to  correct  malpresentations,  they 
should  be  corrected.  In  cases  of  neglected  transverse  presenta- 
tions decapitation  rather  than  version  should  be  performed. 
When  the  anterior  lip  of  the  cervix  descends  in  front  of  the  head  it 
should  be  pushed  back. 

When  rupture  has  actually  occurred,  the  line  of  treatment  de- 
pends upon  the  condition  of  affairs  which  succeed  the  rupture. 
The  foetus  may  be  entirely  within  the  uterus,  but  the  presenting 
part  not  fixed.     In  such  cases  podalic  version  should  be  performed 


412     ABNOEMAL    CONDITIONS    OF    THE   UTEEUS 

at  once,  the  child  and  placenta  being  rapidly  extracted.  Version 
may  increase  the  size  of  the  rent,  but  it  insures  rapid  delivery  and 
should  be  performed  in  all  cases.  After  dehvery  the  rent  should 
be  examined,  and  if  it  is  small,  low  down,  and  closed  by  the  uterine 


i^i'*''*«!frK 


Fig.  144. — Rupture  of  the  Uterus  discovered  Post  Mortem  (Williams). 

A,  cavity  of  uterus  ;  B,  B,  B,  retraction  ring  ;  C,  rupture  ;  D,  cervix.     Sutures  of 

vaginal  tear  in  place. 

contractions,  an  expectant  line  of  treatment  may  be  adopted.  The 
clots  and  any  debris  should  be  removed,  the  uterus  douched,  and  a 
strip  of  iodoform  gauze  passed  into  the  uterus  up  to  the  fundus. 
If  peritonitis  sets  in,  a  laparotomy  should  be  done  and  the  perito- 
neal cavity  washed  out.  The  rent  may  be  large,  the  presenting  part 
fixed  or  near  the  brim,  and  a  part  of  the  foetal  body  in  the  abdom- 


ABNOEMAL    CONDITIONS    OF    THE    UTERUS     413 

inal  cavity.  When  the  head  is  the  presenting  part  the  forceps 
should  be  apphed  and  the  child  rapidly  extracted.  Some  recom- 
mend perforation  before  extraction,  but  this  should  never  be  done 
unless  the  child  is  dead.  If  the  breech  presents,  a  foot  should  be 
brought  down  and  the  child  rapidly  extracted.  The  arms  may  be 
pulled  over  the  head,  but  no  delay  should  be  made  for  fear  of  this, 
as  recommended  in  an  ordinary  breech  dehvery.  The  child  should 
be  pulled  down  rapidly,  the  arms  brought  down  when  the  body  is 
born,  and  the  head  quickly  deUvered.  If  this  procedure  is  im- 
possible, laparotomy  should  be  done,  the  child  removed,  the  rent 
closed,  and  the  abdominal  cavity  irrigated. 

The  entire  foetus  may  have  passed  into  the  abdominal  cavity. 
In  such  cases  laparotomy  and  extraction  of  the  child,  as  described 
above,  is  the  best  treatment.  Fortunately  the  child  very  seldom 
passes  quickly  into  the  abdominal  cavity.  It  does  occasionally, 
however,  and  one  should  be  prepared  to  act  promptly.  The  ac- 
coucheur may  be  some  miles  from  a  hospital,  his  office,  and  a  physi- 
cian. He  has  no  suitable  instruments,  and  is  perhaps  not  sufficient- 
ly skilful  to  do  a  coehotomy  with  a  penknife.  He  must  do  some- 
thing at  once  in  the  majority  of  cases  of  this  form  of  rupture. 
Under  such  circumstances  one  should  not  hesitate.  Introduce  the 
hand  at  once  through  the  vagina  into  the  uterus,  then  through 
tear  into  peritoneal  cavity,  seize  a  foot  and  extract  the  child  by 
way  of  the  uterus  and  vagina.  Remove  the  placenta  at  once  and 
then  pack  the  abdominal  cavity  as  far  as  possible  with  iodoform 
gauze.  Also  pack  the  uterus  until  the  haemorrhage  ceases.  It 
may  be  necessary  to  pack  both  uterus  and  vagina  in  cases  of  uter- 
ine atony  after  packing  the  abdominal  cavity.  Many  years  ago, 
before  Lister  taught  the  science  and  art  of  antiseptics,  the  late  Dr. 
W.  T.  Aikins  had  a  case  of  this  sort.  He  passed  his  hand  into  the 
abdominal  cavity,  extracted  the  child  through  the  utero-vaginal 
canal,  and  his  patient  made  a  good  recovery. 

If  the  rent  is  extensive  and  ragged,  involving  adjacent  struc- 
tures, or  if  there  is  sepsis,  one  should  perform  a  Porro-Csesarean 
section,  or  extirpate  the  whole  uterus.  The  following  summary 
of  directions  may  prove  useful.  Deliver  quickly  and  plug  with 
iodoform  gauze  in  the  great  majority  of  cases.  Perform  a  lapa- 
rotomy, when  the  child  has  passed  into  the  abdominal  cavity,  if 
there  are  at  hand  proper  appliances  and  sufficient  help.  Per- 
form a  Porro,  or  extirpate  the  whole  uterus  in  exceptional  cases. 


414     ABNORMAL    CONDITIONS    OF    THE   UTEEUS 

The  treatment  of  rupture  of  the  uterus  by  packing  with  iodo- 
form gauze  is  now  largely  accepted  as  the  best  in  nearly  all  cases. 
Its  results  during  recent  years  show  to  good  advantage  when  com- 
pared with  those  following  the  more  difficult  operative  procedures. 
For  instance,  Herbert  Spencer  recently  reported  twelve  cases  of 
rupture  of  the  uterus.     In  four  cases  (two  complete  and  two  in- 


FiG.  145.— Uterine  Tamponade  after  Labor.   (Diihrssen's  method.  See  p.  353.) 


complete  ruptures)  treated  by  gauze  packing,  all  the  patients  re- 
covered. In  eight  cases  with  other  forms  of  treatment  (including 
two  abdominal  hysterectomies),  all  died. 

In  this  connection  we  have  to  consider  that  serious  condition 
called  shock,  which  we  find  so  frequently  in  surgical  emergencies. 
We  learn  from  clinical  observation  that  a  woman  after  rupture  of 
the  uterus  is  a  poor  subject  for  a  cutting  operation.  And  yet,  in 
certain  very  rare  cases,  when  the  child  is  in  the  abdominal  cavity 
and  can  not  be  pulled  through  the  uterine  rent  without  undue 
violence,  the  abdominal  section  becomes  necessary. 

There  is  some  difference  as  to  details  of  the  gauze-packing.  In 
the  Rotunda  they  generally  pass  a  thick  plug  of  iodoform  gauze 
through  the  uterine  rent  into  the  abdominal  cavity  for  drainage 
and  to  keep  the  intestines  out  of  the  wound,  and  leave  the  lower 
end  of  the  gauze  in  the  vagina.  In  other  words,  when  there  is  no 
serious  haemorrhage  they  simply  use  the  iodoform  gauze  to  prevent 
sepsis  and  act  as  a  drain;  but  when,  on  the  other  hand,  there  is 
copious  haemorrhage',  they  perform  an  abdominal  section  and  re- 
move the  uterus.     Many,  but  not  all,  use  a  douche  before  intro- 


ABNORMAL    CONDITIONS    OF    THE    UTERUS     415 

ducing  the  gauze.  Herman,  in  doing  so,  moves  the  nozzle  of  the 
syringe  throughout  the  whole  length  of  the  rent  and  through  the 
rent  into  the  peritonaeum.  He  holds  the  perineum  back  with  the 
fingers  to  allow  return  of  the  fluid  with  dislodged  clots.  He  uses 
plenty  of  fluid,  washes  thoroughly,  and  in  cases  of  emergency  uses 
ordinary  tap  water  without  waiting  for  its  steriUzation.  This  douch- 
ing of  the  peritoneal  cavity  is  not  always  necessary,  and  in  cases 
where  there  is  considerable  haemorrhage  is  not  advisable.  Sterilized 
salt  solution  is  the  best  fluid  for  the  intra-peritoneal  douche. 

Diihrssen's  method  differs  materially  from  that  of  the  Rotunda. 
He  passes  the  gauze  through  the  rent  and  plugs  the  abdominal 
cavity  as  high  as  possible,  and  then  the  uterine  cavity  and  vagina 
more  or  less  tightly  (the  uterus  tightly  if  atony  exists).  The 
amount  of  gauze  which  can  be  pushed  into  the  abdominal  cavity 
is  not  so  much  as  some  people  think,  because  the  abdomen  is  not 


Fig.  146. — Partial  Inversion.    Posterior  Wall  of  Uterus,  Internal  View. 
(Tor.  Univ.  Museum.) 

empty,  but  fairly  well  filled.  Afterward  the  tampon,  which  is 
easily  felt,  is  pressed  from  the  abdominal  walls  against  the  uterus. 
Complete  arrest  of  very  severe  haemorrhage  may  thus  be  obtained. 
Diihrssen  lays  more  stress  on  the  arrest  of  bleeding  than  upon  the 
drainage  action  of  the  gauze,  which  he  considers  of  secondary  im- 
portance. 

28 


416     ABNORMAL    CONDITIONS    OF    THE   UTERUS 

In  carrying  out  Diihrssen's  method  (which  I  consider  the  best 
now  known)  it  is  better  as  a  rule  to  leave  the  gauze  undisturbed 
for  a  fairly  long  time,  especially  in  cases  with  considerable  haemor- 
rhage. Slow  withdrawal  of  a  limited  amount  each  day,  from 
the  fourth  to  the  ninth  day,  when  the  removal  of  the  gauze  should 
be  completed,  answers  well.  As  before  mentioned,  iodoform  gauze 
is  not  free  from  risk,  especially  in  anaemic  patients,  but  many  of 
us  have  found  no  serious  poisoning  from  its  retention  from  five 
to  nine  days. 

Inversion  of  the  Uterus. — This  is  an  occurrence  that  but  seldom 
happens ;  probably  once  in  200,000  labors.  It  may  be  inverted  in 
part  only,  or  altogether ;  hence  two  varieties  are  described,  partial 
and  complete.  In  complete  inversion  there  are  three  stages: 
the  fundus  is  inverted  and  passed  down  to,  but  not  past,  the 


Fig.  147. — Partial  Inversion.     Posterior  Wall  of  Uterus,  External  View. 
(Tor.  Univ.  Museum.) 


external  os ;  the  inversion  passes  through  the  os  into  the  vagina ; 
the  inversion  becomes  complete. 

Traction  on  the  cord,  when  it  is  short  and  there  is  a  precipitate 
labor,  is  apt  to  cause  inversion  of  the  uterus  where  there  is  uterine 
inertia.  This  traction  may  be  injudiciously  exerted  by  the  ob- 
stetrician.    Sometimes  the  inversion  is  spontaneous  with  inertia. 


ABNORMAL    CONDITIONS    OF    THE    UTERUS     417 

In  all  cases  there  is  inertia  of  the  uterine  walls.  Its  symptoms  are 
shock  and  hsnmorrhage,  with  vesical  and  rectal  tenesmus.  Ab- 
dominal palpation  reveals  the  depression  or  absence  of  the  fundus, 
and  bimanual  examination  shows  both  this  depression  of  the 
fundus  and   the  presence  of  a  tumor  in  the  A^agina.     It  must   be 


Fig.  148. — Co.mplete  Inversion  of  Uterus  (Bumm). 


diagnosed  from  a  fibrous  polypus  of  the  uterus,  protruding  from 
the  OS  into  the  vagina,  and  the  head  of  a  second  child.  The 
prognosis  is  bad,  more  than  half  the  patients  dying  within  a  few 
hours  after  the  inversion  has  occurred.  Shock  in  most  cases  is 
the  cause  of  death. 

Treatment.  The  patient  should  be  anaesthetized,  the  urine 
drawn  off  with  a  catheter,  and  the  vulva  and  vagina  sterilized. 
Attempts  should  then  be  made  to  replace  the  inverted  uterus, 
first  by  manual  pressure  and  manipulation,  and,  this  failing,  by 
Aveling's  repositor  or  some  similar  instrument. 


418     ABKOEMAL    CONDITIONS    OF   THE    UTERUS 

RETENTION  OF  PLACENTA  AND  ADHESIONS  OF  PLACENTA 

There  has  been  a  certain  amount  of  confusion  about  the  terms 
retention  of  placenta  or  retained  placenta,  and  adhesions  of 
placenta  or  adherent  placenta.  The  simple  meaning  of  the  words 
retention  and  adhesion  should  assist  in  getting  the  correct  idea  of 
the  conditions  referred  to. 

Adhesion  of  the  placenta  for  any  length  of  time  after  the  deliv- 
ery of  the  child  is  extremely  rare.  As  stated  in  connection  with 
normal  labor,  separation  of  the  placenta  is  the  first  step  in  the  third 
stage  and  usually  takes  place  in  a  few  minutes  after  the  expulsion 
of  the  child.  After  separation  the  placenta  passes  wholly  or  partly 
into  the  vagina.  If  there  is  no  interference  the  placenta  is  usually 
expelled  by  the  efforts  of  Nature  in  about  an  hour  (more  or  less) . 
The  obstetrician,  however,  interferes  after  separation  and  endeav- 
ors to  express  the  placenta  by  pressure  over  the  fundus  in  the  man- 
ner recommended  by  Crede.  In  a  certain  proportion  of  cases  he 
is  unable  to  do  this,  and  we  then  have  what  is  technically  known 
as  retained  placenta.  Retention  of  the  placenta  is  generally  due 
to  inertia  of  the  uterus  or  irregular  contraction,  generally  known 
as  hour-glass  contraction  of  the  uterus. 

Hour-Glass  Contraction. — This  is  a  term  applied  to  various  con- 
ditions of  the  uterus,  in  which  the  most  important  element  is  a  con- 
striction of  the  ring  of  Bandl  or  the  retraction  ring.  Among  those 
conditions,  which  are  caused  by  irregular  contractions  of  various 
sets  of  muscular  fibers  in  the  uterus  and  which  are  included  under 
the  term  hour-glass  contraction,  three  especially  may  be  named : 
1.  General  atony  of  the  uterus  followed  by  contraction  at  Bandl 's 
ring.  2.  General  tetanic  contraction  of  the  uterus  followed  by 
relaxation  of  the  upper  segment.  3.  General  contraction  (prob- 
ably tetanic)  of  upper  and  middle  segments  of  the  uterus  gripping 
the  placenta  firmly  without  any  expelling  force. 

In  a  small  minority  of  cases  there  is  adhesion,  which  is  the  cause 
of  the  retention.  Adhesion  of  the  placenta  is  generally  due  to 
disease  of  the  decidua  or  placenta,  which  interferes  with  the  proper 
development  of  the  spongy  layer  of  the  serotina  where  separation 
should  take  place.  When,  as  in  the  majority  of  cases,  it  happens 
that  there  is  intimate  adhesion  of  only  a  portion  of  the  placenta, 
with  detachment  of  the  remainder,  alarming  haemorrhage  may 
ensue. 


EETENTION    OF    PLACENTA  419 

Treatment  for  Retention  of  Placenta. — When  the  placenta  is 

retained  in  the  uterus,  whether  it  be  adherent  or  not,  there  is  only 
one  plan  of  treatment.  Introduce  the  hand  into  the  uterus  and 
bring  down  the  placenta.  When  there  is  hour-glass  contraction 
one  should  not  mistake  the  mucous  membrane  of  the  lower  seg- 
ment for  an  adherent  placenta.  Introduce  one  hand  into  the 
vagina  and  two  fingers  into  the  uterus.  Pass  the  fingers  gently  and 
slowly  through  the  constriction.  At  the  same  time  push  the  uterus 
downward  by  pressure,  with  the  other  hand  over  the  fundus. 
Endeavor  then  to  get  the  edge  of  the  placenta  into  the  constriction. 
Pull  slightly  on  the  edge  thus  coaxed  into  the  canal  and  con- 
tinue pressure  over  the  fundus.  The  whole  procedure  should  be  a 
coaxing  process  slowly  performed.  When  a  goodly  portion  of  the 
placental  mass  gets  into  the  stricture,  relaxation  will  soon  take 
place  with  the  assistance  of  the  gentle  pressure  over  the  fundus. 
In  case  of  failure  with  the  two  fingers,  pass  the  whole  hand  into  the 
uterus  and  push  the  tips  of  the  fingers  (pressed  together  in  the  shape 
of  a  cone)  gently  through  the  constriction,  pressure  being  made 
over  the  fundus  as  before  described.  Push  the  fingers  up  between 
the  placenta  and  uterine  wall,  and  then,  if  possible,  hook  the  fingers 
over  the  upper  edge  of  the  placenta  and  bring  it  down.  It  is  well 
in  any  case  of  retention,  but  especially  important  when  there  is 
adhesion,  to  pass  the  fingers  outside  the  membranes.  When  the 
placenta  is  reached  push  the  finger-tips  between  the  lower  edge  and 
the  uterine  wall.  Continue  to  separate  placenta  from  uterus  until 
the  former  is  detached  in  one  piece.  Be  very  careful  during  this 
procedure  to  keep  steady  but  firm  pressure  over  the  fundus  with  the 
other  hand.  After  complete  detachment  remove  the  whole  pla- 
centa as  before  described.  Then  reintroduce  the  hand  and  ex- 
amine carefully  to  ascertain  whether  any  fragments  have  been  left 
behind  and  remove  them.  Some  obstetricians  use  a  curette  after 
removing  as  much  as  possible  with  the  fingers,  but  the  use  of  this 
instrument  under  such  circumstances  is  so  dangerous  that  I  think 
it  should  be  forbidden. 

Sometimes  it  is  impossible  to  separate  the  placenta  in  one  piece. 
In  one  case  I  had  to  separate  it  piece  by  piece,  and  had  very  great 
difficulty  in  detaching  certain  portions.  After  the  removal  of  all 
the  fragments  I  feared  that  I  had  left  some  pieces  adherent,  but  I 
also  feared  that  I  had  in  places  scraped  away  pieces  of  the  uterine 
wall.     The  patient,  who  had  lost  much  blood,  made  a  good  but 


420     ABNOEMAL    CONDITIONS    OF    THE    UTERUS 

slow  recovery.  Herman  says :  "  I  have  only  once  met  with  a  pla- 
centa so  adherent  that  I  could  not  remove  it  entire,  but  had  to 
scrape  it  off  and  get  it  away  in  small  fragments.  The  patient, 
thanks  to  antiseptic  douches,  got  well.''  I  quote  this  partly  be- 
cause of  the  last  sentence.  If,  however,  the  operator  does  not 
introduce  any  septic  matter  into  the  uterus,  what  need  is  there  for 
antiseptic  douches?  My  patient,  without  antiseptic  douches,  got 
well. 

MASTITIS 

Varieties. — Some  members  of  the  Dublin  School  divide  mastitis 
into  two  varieties:  parenchymatous,  inflammation  of  the  milk 
ducts ;  interstitial,  inflammation  of  interstitial  tissue.  This  classi- 
fication, while  not  quite  correct  either  clinically  or  anatomically, 
is  much  better  than  the  old  classification  of  Velpeau  so  generally 
accepted  for  many  years,  into  superficial  or  subcutaneous,  glan- 
dular, and  submammary. 

There  is  but  little  known  about  the  pathology  of  the  milder 
forms  of  mastitis.  It  is  probable,  however,  that  bacteria  some- 
times enter  the  breasts  through  the  milk  ducts,  giving  rise  to  the 
parenchymatous  variety ;  and  sometimes  (more  frequently  I  think) 
by  means  of  the  lymphatics  passing  through  an  excoriation  or 
fissure  into  the  interstitial  tissues,  hence  the  interstitial  variety. 

S)rmptoms. — There  is  sometimes  a  hard,  painful  lump,  fairly 
well  defined — i.  e.,  with  a  sharp  line  of  demarcation  between  the 
inflamed  and  healthy  portions  of  the  gland.  This  is  at  first  usually 
triangular  in  shape,  with  the  apex  at  the  nipple.  Jellett  thinks 
that  this  form  of  inflammation  is  parenchymatous  and  generally 
tends  to  subside.  Whether  this  is  correct  or  not  I  can  not  say,  but 
we  certainly  do  find  a  distinct  lump  of  this  kind  sometimes  disap- 
pear under  appropriate  treatment.  On  the  other  hand,  we  some- 
times find  a  diffused  irregular  swelling  which  can  not  be  clearly 
and  definitely  located.  This  is  probably  interstitial,  and  more 
often  tends  to  suppurate. 

In  both  varieties  the  whole  breast  is  generally  at  first  distended 
and  painful.  A  certain  portion  soon  becomes  more  painful.  The 
local  signs  are  soon  accompanied  by  severe  constitutional  dis- 
turbances, such  as  furred  tongue,  rapid  pulse,  higher  temperature, 
and  general  malaise.  In  severe  cases  suppuration  soon  occurs, 
forming  the  ordinary  mammary  abscess.     It  is  frequently,  if  not 


MASTITIS 


421 


generally,  impossible  to  recognize  the  presence  of  pus  by  the  de- 
tection of  fluctuation,  but  the  presence  of  oedema  over  the  painful 
portion  may  be  considered  a  positive  sign  of  abscess.  In  some 
cases  there  is  no  general  distention  and  pain,  the  first  symptom 
being  localized  jjain  with. more  or  less  hardness.     In  any  case  where 


Fig.  149. — Breast  of  Pregnancy. 

Showing  extensive  pigmentation  of  tiie  skin  over  and  beyond  the  breast,  striae  on 
breast,  areola,  slight  secondary  areola,  tubercles  of  Montgomery,  and  normal 
nipple. 


the  constitutional  and  local  symptoms  have  continued  for  forty- 
eight  hours,  one  should  conclude  that  there  is  pus,  and  at  once 
institute  proper  treatment. 

Frequency. — Statistics  as  to  frequency  vary  greatly.     Some 
authorities  state  that  about  6  per  cent,  of  the  nursing  women  are 


422     ABNORMAL    CONDITIONS    OF    THE    UTERUS 

afflicted  with  mastitis.  In  our  Burnside  Maternity  the  percent- 
age is  certainly  less  than  1  per  cent.  One  can  not  give  exact 
figures  about  mastitis  because  of  the  difficulty  of  distinguishing 
between  painful  breast  engorgement  and  mastitis,  but  one  can 
speak  definitely  as  to  mammary  abscess.  Out  of  two  thousand 
consecutive  cases  at  our  Burnside  Maternity  there  have  been  six 
mammary  abscesses ;  of  these,  two  had  mastitis  when  admitted, 


Fig.  150. — A,  Parenchymatoiis  mastitis  ;    B,  infected  milk  ducts  ;   C,  erosion  of 
nipple  ;  D,  fissure  at  base  of  nipple  ;  E,  interstitial  mastitis. 

three  were  attacked  within  a  very  short  period,  while  things  were 
going  "queer,"  and  the  other  had  a  very  severe  mastitis  with 
abscess,  probably  through  some  error  in  our  technique.  A  great 
deal  depends  on  the  nursing  in  these  cases,  and  it  is  very  important 
for  one  to  become  skilled  in  technique  and  thus  able  to  properly 
instruct  the  nurse. 


TREATMENT 

Two  things  should  be  kept  in  view  in  connection  with  the  pre- 
vention of  mastitis :  1.  The  care  of  the  nipples.  2.  The  use  of  the 
breast-binder. 

The  Care  of  the  Nipples. — In  speaking  of  the  hygiene  of  preg- 
nancy and  also  of  the  puerperal  state,  some  directions  have  been 


MASTITIS 


423 


given  as  to  the  care  of  the  nipples.  Although  differing  from  many 
excellent  obstetricians  I  desire  again  to  express  the  opinion  that 
any  efforts  to  harden  the  nipples  by  the  application  of  spirit  lotions 
are  harmful.  If  any  application  is  made  it  is  better  to  use  some- 
thing which  will  soften  the  surface  of  the  nipples,  such  as  lanolin, 
because  a  soft  or  a  softened  nipple  will  not  crack  so  readily  as  a 
nipple  hardened  by  astringent  or  spirit  lotions. 

There  are  four  varieties  of  troublesome  nipples  that  will  require 
treatment.  (For  directions  as  to  fiat  or  inverted  nipples,  see  page 
158.)  1.  Sore  nipples  cause  great,  sometimes  intolerable,  pain, 
and  are  also  predisposing  causes  of  mastitis.  There  are  three 
varieties:  excoriation,  fissure  of  the  summit,  and  fissure  of  the 
base.  2.  Excoriation  of  the  nipples  is  caused  by  maceration  and 
destruction  of  the  epithelial  covering.     A  raw  surface  is  produced, 


F. 

lor' 

106' 

105"= 

104° 

103° 

102° 

101° 

100° 

99° 

98° 

97° 

O 

^, 

\ 

>L 

A 

V^ 

>•- — 

-•-^ 

i 

\ 

-»-— 

■*""• 

^s. 

/ 

\ 

A 

A 

n 

A 

"/ 

^- 

A- 

-•». 

/ 

\/ 

V 

r 

\^ 

\h 

A 

^./N 

/ 

V 

^A 

V 

Y 

\ 

V 

V 

\A 

a 

V 

\     / 

V 

% 

M 

Pulse 

E 

98 

90 

92 

91 

96 

90 

88 

90    1  81 

130 

121 

96 

80 

81 

96 

98 

100 

108 

112 

91 

96 

100 

120 

136 

116 

100 

81 

88 

Fig.  151. — Chart  showing  Rise  of  Temperature  from  Sore  Nipples. 


looking  like  a  small  strawberry,  and  very  painful  when  touched. 
3.  Fissure  of  the  summit  is  a  linear  ulcer  running  generally  from 
the  circumference  to  the  center.  4.  Fissure  of  the  base  is  a 
linear  ulcer  running  transversely,  and  is  generally  the  worst  form 
of  sore  nipple. 

In  all  cases  wash  the  nipple  after  nursing.     For  ordinary  ex- 
coriation apply  first  a  mixture  of  castor-oil  and  bismuth  (equal 


424     ABNOEMAL    CONDITIONS    OF    THE    UTEEUS 

parts),  as  recommended  by  Hirst.  This  mixture  may  also  be 
applied  to  a  slight  fissure  of  the  summit.  If  this  does  not  effect 
any  improvement,  apply  orthoform — either  in  the  form  of  a  powder 
or  an  ointment  having  10  per  cent,  orthoform  and  90  per  cent, 
lanolin.  The  orthoform  is  a  mild  antiseptic,  and  also  produces 
local  anaesthesia,  which  lasts  for  some  hours  after  its  application. 
Another  plan  of  treatment  in  the  Burnside  is  to  carefully  wash  the 
nipple  after  nursing  with  a  solution  of  boric  acid;  then  apply  a 
solution  of  carbolic  acid,  1-40 ;  then  soak  some  absorbent  cotton  in 
a  solution  of  boric  acid,  place  it  over  the  nipple  and  have  it  retained 
in  position  by  the  breast-binder.  In  other  words,  wash  nipples, 
apply  carbolic  solution,  and  then  apply  a  boracic  poultice  and  re- 
tain it  until  the  next  time  of  nursing,  A  piece  of  oil  silk  or  gutta- 
percha tissue  may  be  placed  over  the  poultice. 

In  case  of  fissure  of  either  the  summit  or  the  base,  nothing  is 
more  satisfactory  than  the  application  of  the  solid  stick  of  nitrate 
of  silver,  as  our  fathers  used  it  long  ago.  The  parts  should  be 
thoroughly  dry.  Separate  the  opposed  surfaces,  apply  the  stick 
lightly  to  bottom  and  sides  of  the  fissure,  and  if  the  fissure  is 
deep  apply  absorbent  cotton  between  the  two  surfaces.  After 
opposing  surfaces  have  become  healthy  in  appearance  apply  the 
compound  tincture  of  benzoin,  two  or  three  layers,  with  a  camePs- 
hair  brush. 

When  nursing  causes  extreme  pain  after  treatment  as  described, 
use  a  nipple-shield.  This  is  at  first  refused  by  the  baby,  as  a  rule, 
but  a  good  nurse  can  generally  get  the  baby  to  take  the  shield  after 
a  few  trials.  Apply  the  flat  surface  tightly  to  the  breast,  and  if  the 
child  will  not  seize  the  rubber  nipple,  or  will  not  retain  it,  press  a 
little  milk  into  the  shield  with  the  fingers  placed  on  the  surface  of 
the  breast  outside  the  base.  Miss  MacKellar  finds  in  the  Burnside 
that  the  best  form  of  nipple-shield  is  one  made  of  glass  with  an 
india-rubber  teat  attached.  I  also  use  this  kind  in  my  private 
practice.  After  using  a  shield,  always  wash  it  carefully  and  then 
place  it  in  a  saturated  solution  of  boric  acid  until  again  wanted. 
While  the  nipple  shield  generally  answers  a  good  purpose,  it  hap- 
pens occasionally  that  it  can  not  be  used.  This  is  true  especially 
in  the  bad  form  of  fissure  of  the  base,  when  the  drawing  of  the  nip- 
ple into  the  shield  opens  the  opposed  surfaces  at  each  nursing. 

It  is  sometimes  necessary  to  stop  nursing  for  a  time — two,  three, 
or  four  days,  or  sometimes  altogether — i.  e.,  to  "  dry  the  breast." 


MASTITIS  425 

When  the  breast  is  given  a  rest  as  to  nursing  it  becomes  distended 
with  milk.  If  such  distention  is  present  notwithstanding  the  use 
of  the  breast-binder,  it  should  be  relieved  by  the  process  of  milking 
the  nipples  with  the  fingers,  much  as  a  milkmaid  milks  her  cow,  or 
by  the  use  of  the  breast-pump. 

The  Use  of  the  Breast-Binder. — In  speaking  of  the  puerperal 
state  I  referred  especially  to  the  use  of  the  breast-binder  for  disten- 
tion of  the  breasts  a  few  days  after  labor.  The  judicious  use  of 
such  a  binder  prevents  much  discomfort  as  well  as  actual  pain,  and 
also  tends  to  prevent  mastitis. 

Massage. — I  desire  to  return  to  this  subject  and  refer  to  the  pro- 
cedure in  connection  with  pathological  conditions  of  the  nipples  or 
breasts.  The  use  of  the  breast-binder  fortunately  makes  massage 
absolutely  unnecessary  for  what  may  be  called  physiological  ful- 
ness or  distention  of  the  breasts.  In  certain  cases,  however,  which 
appear  to  be,  or  are  actually  becoming,  pathological,  in  spite  of  the 
use  of  the  binder  or  careful  treatment  of  the  nipples,  a  modified 
form  of  massage  sometimes  has  a  good  effect.  I  do  not  refer  in  this 
connection  to  rubbing  from  the  circumference  toward  the  nipples, 
but  to  an  altogether  different  sort  of  massage  which  I  have  used 
lately,  and  which,  as  far  as  I  know,  was  first  described  by  Bacon 
of  Chicago.  The  fulness  of  the  breasts  after  labor  is  not  primarily 
due  to  an  accumulation  of  secreted  milk,  but  rather  to  a  distention 
of  the  blood  and  lymph  vessels.  The  object  of  the  modified  mas- 
sage is  to  relieve  the  painful  engorgement  by  emptying  the  congested 
vessels.  Bacon  does  this  by  beginning  outside  of  and  above  the 
breast  and  rubbing  in  the  direction  of  the  venous  and  lymph  flow 
toward  the  axillary  and  subclavian  trunks.  After  the  surrounding 
area  is  massaged,  the  breast  itself,  or  a  portion  of  it  near  the  per- 
iphery, may  be  gently  rubbed,  but  always  in  a  direction  away 
from  the  nipple.     No  pain  should  be  caused  by  this  manipulation. 

Abnormalities  of  Milk  Secretion. — ^Agalactia  means  a  marked 
diminution  of  mammary  secretion. 

Galactorrhoea  means  excessive  mammary  secretion.  The  sup- 
ply of  milk  may  be  so  abundant  that  it  is  constantly  escaping 
from  the  nipples.  The  milk  is  generally  thin  and  watery,  and  the 
health  of  the  patient  is  impaired. 

Treatment. — Apply  a  breast-binder;  administer  tonics,  espe- 
cially strychnia,  belladonna,  and  arsenic;  and  saline  laxatives. 
Potassium  iodide,  so  often  recommended,  is,  I  think,  worse  than 


426      ABNORMAL    CONDITIONS    OF    THE    UTERUS 

useless.     In  the  majority  of  cases  lactation  should  be  discontinued 
in  the  interest  of  both  mother  and  babe. 

Galactocele  means  the  condition  in  which  a  lactiferous  duct  is 
completely  blocked.  It  may  be  single  or  multiple,  and  affect  one 
or  both  breasts.  Sometimes  the  fluid  part  becomes  absorbed, 
and  the  casein  and  fat  become  inspissated;  or  a  cyst  containing 
both  fluids  and  solids  may  be  formed.  Diagnosis  is  sometimes 
difficult. 

Treatment. — Make  a  free  incision  (not  a  puncture),  clear  out 
the  contents,  wash  out,  and  apply  pressure. 

Treatment  of  Mammary  Abscess. — As  soon  as  the  existence  of 
a  mammary  abscess  is  suspected  one  should  act  promptly  as  fol- 
lows: Clean  the  skin  over  the  breast,  get  an  assistant  to  give  an 
anaesthetic,  make  a  deep  incision  in  the  most  dependent  portion  of 
the  suspected  abscess  cavity,  cutting  in  a  line  toward  the  nipple, 
make  the  incision  long  enough  to  admit  the  index  finger,  allow  the 
pus  to  run  out  of  the  opening,  pass  the  finger  in  and  break  down 
all  the  diseased  tissues  so  as  to  destroy  the  walls  of  the  various 
loculi  of  the  honeycombed  mass  and  form  one  cavity,  scrape  the 
wall  of  this  cavity  thoroughly  with  the  tip  of  the  finger  or  with  a 
dull  metallic  curette,  douche  out  the  cavity  and  plug  it  fairly  tight 
with  iodoform  gauze.  Apply  a  breast-binder,  not  too  tightly  lest 
it  prevent  the  secretion  of  milk  in  the  sound  breast.  Remove  the 
gauze  daily,  wash  out,  and  reintroduce  the  gauze,  as  long  as  pus  is 
found — generally  from  two  to  eight  days.  After  this  do  not  pack 
the  cavity,  but  introduce  a  piece  of  gauze  to  keep  the  skin  wound 
open,  put  a  pad  of  absorbent  or  sheep's  wool  over  this  portion  of 
the  breast,  and  a  breast-binder  over  all.  Or  the  breast  may  be 
strapped  and  the  strapping  may  be  left  on  three  or  four  days. 
This  is  not  so  comfortable  as  the  bandage,  and  the  removal  of  the 
strapping  causes  much  pain.  The  breast  may  be  supported  by  a 
figure-of-eight  bandage.  The  pressure  obliterates  the  cavity  after 
you  stop  the  plugging,  and  the  wound  is  healed  in  from  ten  to 
twenty  days  after  incising  the  abscess.  If,  when  you  make  your 
incision,  you  find  no  pus,  no  harm  will  be  done.  In  fact  the  result- 
ing haemorrhage  will  probably  relieve  tension  and  thus  lessen  the 
pain.  Plugging  in  such  a  case  will  not  be  necessary,  and  suturing 
the  wound  is  not  advisable.  The  child  should  not  nurse  from  the 
diseased  breast  so  long  as  there  is  pus  in  it. 


CHAPTER  XX 

THE  EMOTIONAL  ELEMENT  IN   THE  PUERPERAL  PERIOD, 
AND  PUERPERAL  INSANITY 

EFFECTS  OF  EMOTIONAL  DISTURBANCE 

In  the  literature  of  thirty  years  ago  we  find  many  references  to 
serious  effects,  puerperal  fever,  eclampsia,  mania,  etc.,  produced  by 
emotional  causes,  such  as  worry,  fright,  anger,  and  the  like.  More 
recent  developments  showed  conclusively  that  many  of  the  results 
referred  to  were  due  to  septicaemia.  The  innumerable  discussions 
on  sepsis  and  the  various  means  adopted  for  its  prevention  have 
to  a  certain  extent  overshadowed  the  emotional  element  in  the 
puerperium.  Many  go  so  far  as  to  deny  that  simple  emotions  can 
cause  serious  rise  of  temperature.  I  believe,  however,  that  very 
serious  results  may  follow  causes  which  are  purely  nervous  in  their 
origin. 

Cases. — The  following  brief  notes  of  a  few  among  many  cases 
which  have  come  under  my  notice  will  illustrate  some  phases  of 
the  subject. 

I.  Mrs.  A.,  aged  twenty-three.  Unusually  healthy  and  free  from 
hysteria.  Second  labor :  normal  until  fifth  day,  when  I  found  her  condition 
quite  serious.  She  was  weeping,  had  a  severe  rigor,  temperature  104°, 
pulse  125,  milk  secretion  and  lochia  normal.  On  inquiry,  found  she  had 
had  a  dispute  with  her  nurse,  who  was  acting  badly  in  various  ways,  but 
especially  in  her  treatment  of  the  babe.  The  husband  was  sent  for  and 
the  nurse  at  once  discharged.  In  the  evening,  temperature  and  pulse  were 
nearly  normal,  and  on  the  following  morning  patient  felt  perfectly  well. 

II.  January  22,  1889.  M.  H.,  unmarried.  Labor  normal.  Temper- 
ature normal  until  tenth  day,  when  she  was  visited  by  her  mother,  who 
had  an  interview  with  her  alone.  After  the  mother  left,  the  matron  found 
patient  much  excited  and  crying.  Temperature  105°,  pulse  120.  Next 
morning  temperature  and  pulse  were  normal,  and  remained  so  until  she 
went  out  on  the  fifteenth  day  after  labor. 

427 


428        ELEMENT    IN    THE    PUERPERAL    PERIOD 

III.  Mrs.  A.,  aged  twenty-seven.  IV  para,  healthy.  Labor  normal. 
Symptoms  of  slight  septicaemia  appeared  on  fourth  day.  On  four  dif- 
ferent occasions  during  four  weeks  the  temperature  rose  suddenly  from 
emotional  causes.  There  happened  to  be  an  entire  absence  of  that  sym- 
pathy which  should  exist  between  patient  and  nurse,  and  the  two  were 
continually  at  "cross  purposes."  The  nurse  was  honest  and  conscien- 
tious, but  singularly  injudicious,  and  acted  in  such  a  way  as  to  be  a  con- 
tinuous source  of  irritation  to  her  patient.  On  the  twelfth  day  an  accident 
happened  to  the  babe,  which  much  alarmed  the  mother.  She  became 
greatly  excited,  and  I  was  sent  for  but  did  not  arrive  until  two  hours  had 
expired.  In  the  meantime  the  nurse  was  much  distressed  and  went  re- 
peatedly to  the  window  to  look  for  me,  and  finally  became  as  much  excited 
as  her  patient,  and  wondered  if  the  "doctor  would  never  come."  On  my 
arrival  I  found  the  patient  in  a  serious  condition.  She  had  a  rigor,  tem- 
perature 104.5°,  pulse  120.  There  appeared  to  be  in  this  patient  a  com- 
bination of  septicsemia  and  emotional  fever.  She  was  confined  to  bed  six 
weeks,  but  made  a  perfect  recovery. 

Conclusions. — It  is,  of  course,  difficult  to  arrive  at  definite  con- 
clusions with  mathematical  exactness,  but  I  think  there  can  be  no 
doubt  in  Cases  I  and  II  that  the  rise  of  temperature  and  accom- 
panying symptoms  were  caused  entirely  by  emotional  reactions. 
I  think  that  an  emotional  explosion  may  cause  a  rise  of  temperature 
to  the  extent  of  seven  degrees  or  more  within  a  short  time — cer- 
tainly less  than  an  hour,  perhaps  a  few  minutes. 

Case  III  suggests  the  question,  May  emotional  disturbance 
during  the  puerperal  period  produce  serious  effects  and  even  en- 
danger life?  I  believe  that  it  may.  In  this  case  I  thought  the 
dangers  to  the  patient  were  vastly  increased  by  purely  emotional 
causes,  due  principally  to  the  want  of  tact  of  the  nurse.  It  seems 
to  me  that  any  one  who  believes  that  a  nervous  cause  may  produce 
an  elevation  of  temperature  to  the  extent  of  six  or  eight  degrees, 
can  scarcely  refuse  to  assent  to  the  opinion  that  in  many  a  serious 
case,  when  life  is  in  danger,  such  nervous  disturbance  may  turn  the 
balance  in  the  wrong  direction.  It  is  generally  admitted  that 
mental  emotions  play  an  important  part  in  the  causation  of  eclamp- 
sia and  puerperal  mania. 

I  sometimes  fear  that  certain  evils  have  arisen  out  of  our  mod- 
ern methods  of  laboratory  and  hospital  teaching  as  compared  with 
the  old-fashioned  apprentice  system.  It  appears  to  me  that  there 
is  at  the  present  time  considerable  danger  that  we  are  cultivating 
science  at  the  expense  of  art  in  our  profession.     I  have  noticed  in 


EFFECTS    OF    EMOTIONAL   DISTURBANCE       429 

medical  students,  trained  nurses,  and  resident  physicians  and  sur- 
geons in  hospitals,  a  tendency  to  look  upon  the  sick  and  wounded 
as  mere  machines,  and  not  as  fellow  creatures  made  of  flesh  and 
blood,  and  endowed  with  nervous  organizations  which  are  capable 
of  unlimited  suffering. '  I  have  seen  many  acts  of  positive  cruelty 
on  the  part  of  those  who  appear  to  aim  at  treating  the  diseases 
and  injuries,  and  not  the  patients. 

If  it  is  granted  that  the  emotional  element  in  the  puerperal  state 
is  a  powerful  factor  for  good  or  evil,  we  must  of  necessity  agree  that 
it  is  important  that  we  should  ever  endeavor  to  treat  the  pecu- 
liarities and  idiosyncrasies  of  our  patients,  as  well  as  the  serious 
ailments  and  emergencies  which  may  arise.  We  should  always 
strive  to  guard  against  undue  excitement  from  any  cause.  Much 
depends  upon  the  manner  and  methods  of  the  obstetrician.  He 
should  avoid  what  may  be  called  "  fussiness,"  but  at  the  same 
time  be  ever  on  the  alert.  He  should  be  quiet  and  kind  without 
being  weak  and  irresolute.  In  the  lying-in  chamber  he  is  watching 
what  should  be  a  physiological  process  in  one  who  is  fulfilling  the 
noblest  function  with  which  God  has  endowed  her.  He  should, 
so  far  as  possible,  sink  self  into  oblivion  and  think  only  of  the  inter- 
ests of  her  whom  he  is  called  to  serve.  He  should  have  his  obstet- 
rical satchel  well  equipped;  he  should  be  armed  with  a  supreme 
knowledge  of  the  best  definite  method  of  treating  all  emergencies ; 
but  he  should  keep  his  satchel  and  his  knowledge  in  the  background 
until  they  are  actually  required.  He  should  use  all  the  tact  with 
which  he  is  endowed,  and  at  the  same  time  exhibit  unlimited  firm- 
ness concealed  under  a  kind  and  gentle  manner.  He  should  make 
all  the  surroundings  for  his  patient  as  cheerful  as  possible,  while 
enjoining  perfect  rest  and  quiet.  He  should  strive  to  imbue 
nurses  and  immediate  friends  with  the  ideas  herein  expressed,  and 
if  possible  keep  all  curious  visitors  and  gossiping  neighbors  out  of 
the  house. 

Possibly  I  may  attach  too  much  importance  to  what  may  be 
considered  small  matters;  but  it  has  appeared  to  me  that  in  the 
practice  of  our  art  nothing  can  be  deemed  small.  The  success  of 
the  physician  or  surgeon  depends  on  the  strictest  observance  of 
things  great  and  small,  down  to  the  most  minute  details.  The  most 
successful  in  our  noble  sphere  of  alleviating  the  ailments  of  our 
suffering  fellow  creatures  have  at  all  times  been  acutely  observant, 
exceedingly  watchful,  and  ever  kind  and  gentle.     In  the  practice 


430       ELEMENT    IN   THE    PUERPEEAL   PERIOD 

of  obstetrics  we  should  be  second  to  none  in  the  rigid  and  careful 
observance  of  all  the  rules,  whether  manifestly  great  or  seemingly 
insignificant,  which  are  likely  to  conduce  to  the  welfare  of  our 
patients. 

PUERPERAL   INSANITY 

Insanity  of  pregnancy,  or  of  the  puerperal  period,  or  of  lac- 
tation, does  not  differ  in  symptoms  from  ordinary  insanity.  The 
symptoms  most  commonly  appear  within  six  or  seven  weeks 
after  labor,  but  frequently  near  the  end  of  lactation  and  occa- 
sionally during  pregnancy.  The  prodromal  stage  is  generally 
short  and  hallucinations  soon  appear.  Constipation  is  frequently 
very  marked. 

Melancholia  is  the  most  serious  form  and  is  frequently  incurable. 
One  may  hope,  however,  for  a  cure  in  the  majority  of  cases  in 
about  nine  or  ten  months.  One  may  look  for  recovery  from 
mania  in  about  six  or  seven  months,  but  sometimes  the  mania  is 
incurable.  In  monomania,  or  hysterical  insanity  or  transitory 
frenzy,  rapid  recovery  generally  takes  place. 

Treatment. — When  septic  infection  is  present  it  should  receive 
appropriate  treatment;  otherwise,  the  most  important  considera- 
tions are  quiet,  rest,  watchful  care,  and  nourishing  diet.  Much 
depends  on  the  tact  and  judgment  of  the  nurses  or  the  friends  in 
charge.  The  patient  should  never  be  left  alone.  A  "transitory 
frenzy  "  in  the  shape  of  aversion  to  her  babe  may  suddenly  appear. 
In  such  a  case  the  child's  life  is  endangered.  A  suicidal  tendency 
often  develops.  The  patient  often  takes  a  strong  dislike  to  all 
those  she  loved  best  during  her  sane  moments.  She  sometimes 
takes  a  sudden  dislike  to  a  nurse  she  formerly  liked.  Under  such 
circumstances  one  whom  she  now  dislikes  should  keep  out  of  her 
sight,  though  it  be  her  husband,  mother,  or  sister.  When  she 
refuses  to  take  food  force  must  be  used.  One  of  the  most  com- 
mon symptoms  is  sleeplessness.  For  the  treatment  of  this  the 
most  suitable  hypnotics  are  hydrobromate  of  hyoscine,  chloral 
hydrate,  trional,  sulphonal,  and  chloralamide. 

The  most  important  question  for  consideration  comes  up  in 
connection  with  the  advisability  of  sending  the  patient  to  an 
asylum  for  the  insane.  The  relatives  generally  object  to  this. 
Many  physicians  also  object  on  account  of  the  after-effect  on  the 
patient.     Most  of  our  asylum  physicians  tell  us  that  it  is  greatly 


PUERPERAL    INSANITY  431 

in  the  interest  of  all  such  patients  to  send  them  at  once  to 
asylums.  When  the  patient  refuses  to  take  food,  or  when  she 
turns  against  her  nurse  or  nurses,  or  when  she  shows  any  homi- 
cidal or  suicidal  tendency,  she  should  certainly  be  sent  to  an 
asylum  as  soon  as  possible.  In  mild  cases  most  physicians  will 
probably  prefer  to  keep  the  patients  at  their  own  homes.  This 
always  means  some  risk,  which  should  be  fully  explained  to 
the  friends. 


29 


CHAPTER  XXI 


LISTERISM  AND  OBSTETRICS 

Without  discussing  in  detail  the  exact  meaning  of  the  word 
Listerism,  we  shall  suppose  that  it  includes  the  principles  and  prac- 
tice of  modern  aseptic  and  antiseptic  medicine  in  all  its  depart- 
ments, although  the  term  antiseptic  surgery  is  probably  the  one 
most  commonly  used.  Frederick  Treves,  in  his  paper  on  The 
Progress  of  Surgery  (The  Practitioner),  speaks  as  follows  about 
Lister  and  his  work : 

"The  great  feature  in  Victorian  surgery  has,  it  is  needless  to 
say,  been  the  introduction  of  the  antiseptic  method,  and  the  great 

name  which  stands  out  above  all 
,  ''  others  in  the  array  of  Victorian 

surgeons  is  the  name  of  Lister. 

' '  Lister  created  anew  the  an- 
cient art  of  healing;  he  made  a 
reality  of  the  hope  which  had 
for  all  time  sustained  the  sur- 
geon's endeavors;  he  removed 
the  impenetrable  cloud  which 
had  stood  for  centuries  between 
great  principles  and  successful 
practice,  and  he  rendered  pos- 
sible a  treatment  which  had 
hitherto  been  but  the- vision  of 
the  dreamer.  The  nature  of  his 
discovery  —  like  that  of  most 
great  movements — was  splendid 
in  its  simplicity  and  magnifi- 
cent in  its  littleness.  To  the  surgeon's  craft  it  was  but  'the  one 
thing  needful.'  With  it  came  the  promise  of  a  wonderful  future, 
without  it  was  the  hopelessness  of  an  impotent  past.  It  might 
well  have  been  in  Browning's  mind  when  he  wrote — 

"Oh!  the  little  more  and  how  much  it  is  ! 
And  the  little  less  and  what  worlds  away  !  " 
432 


Fig.  152. — Lord  Lister. 


LISTERISM    AND    OBSTETRICS 


433 


Semmelweiss,  Fordyce  Barker,  and  Lister  are  three  men  whose 
names  are  inseparably  connected  with  the  great  advances  in  mid- 
wifery during  the  hist   fifty  years.     Semmelweiss   made  a  great 
discovery  which   the  world  did   not   properly   appreciate   during 
his  lifetime.     Barker  made  many  improvements  in   the  art  of 
midwifery,  which  obstetricians 
recognized  ;    but    during    his 
later  years  hugged  a  mistaken 
theory   as   to    the    nature    of 
puerperal  fever  long  after  it 
had    been    exploded.      Lister 
made   the   greatest  discovery 
of  last  century,  which,  fortu- 
nately, the  world  fully  appre- 
ciates. 

Semmelweiss,  in  184  7, 
clearly  and  positively  enun- 
ciated the  view  that  puerperal 
fever  was  caused  by  the  in- 
troduction of  putrescent  sub- 
stances deposited  in  or  about 
the  genital  tract  of  the  par- 
turient woman.     He  thought 

that  such  noxious  substances  were  in  reality  decomposed  ani- 
mal matter,  and  also  considered  it  possible  that  such  offending 
material  might  be  developed  in  the  body  of  the  patient  (auto- 
genetic).  These  views  were  adopted  by  a  limited  number,  and 
from  the  year  1848  antiseptics  have  been  used  to  a  greater  or 
lesser  extent.  Fordyce  Barker  commenced  the  use  of  antiseptics, 
including  antiseptic  vaginal  douches,  about  the  year  1854.  In 
addition  to  the  use  of  antiseptics  he  practised  the  strictest  clean- 
liness, and  in  his  teaching  urged  the  importance  of  the  same. 

Lister,  for  years  before  he  discovered  the  relationship  between 
microbes  and  bad  results  in  wound-infection,  recognized  the  evil 
of  putrefaction  in  surgery  and  endeavored  to  counteract  it  by 
cleanliness  and  the  use  of  deodorant  lotions.  L^p  to  this  time  he 
had  advanced  as  far  as  Semmelweiss  and  Barker,  but  no  farther. 
Fortunately,  however,  he  did  not  stop  here,  but  went  on  with  his 
good  work,  and  applied  his  knowledge  of  Pasteurism  to  surgery. 
His  grand  discovery  stimulated  surgeons  and  obstetricians  in  all 


Fig.  153. — Semmelweiss. 


434 


LISTEEISM    AND    OBSTETEICS 


parts  of  the  world,  and  caused  them  to  make  special  efforts  to 
avoid  septicaemia. 

Listerism  has  completely  revolutionized  our  views  and  our 
methods  in  obstetrics.  The  idea  that  puerperal  fever  is  a  specific 
disease,  like  scarlet  fever,  is  replaced  by  the  opinion  that  it  is  a  pre- 
ventable disease  produced  by  microbes  which  come  from  without. 
Auto-genetic  puerperal  fever,  as  it  was  formerly  understood,  is  not 

now  recognized.  Our  former 
theories  as  to  varied  forms  of  in- 
flammation occurring  during  the 
puerperal  period  are  changed  and 
simplified,  because  we  have  ac- 
cepted Lister's  views  as  to  the 
causes  of  surgical  diseases. 

About  the  year  1872  obstet- 
ricians commenced  to  use  Lis- 
terian  methods,  especially  in  large 
maternity  hospitals.  The  new 
ideas  and  the  new  methods 
spread  rapidly  from  hospital  to 
hospital  in  Germany,  France, 
Great  Britain,  America,  and 
other  countries.  Rigid  antiseptic  methods  were  adopted,  with 
marvelous  changes  in  the  mortality  rates. 

The  wonderful  reduction  in  mortality  rates  does  not,  however, 
tell  the  whole  story.  It  tells  us  that  many  thousands  of  lives  have 
been  saved  during  the  last  thirty  years  through  the  application  of 
Listerian  methods ;  but  it  does  not  tell  us  how  many  other  thou- 
sands have  been  relieved  from  the  ill  effects  of  septic  infection 
which  kills  not,  but  cripples  sadly.  It  is  very  unsatisfactory,  in 
this  connection,  to  find  that  the  general  results  in  private  practice 
have  not  kept  pace  with  those  in  lying-in  hospitals.  The  annual 
reports  of  the  Registrar- General  of  Great  Britain  show  that  the 
death-rates  from  childbirth  have  not  appreciably  diminished  in 
England  and  Wales.  In  the  United  States  and  Canada  the  mor- 
tality from  puerperal  septicemia  has  probably  diminished  during 
the  last  twenty  years,  but  it  is  still  very  high. 


Fig.  154. — Fordyce  Barker. 


PUERrERAL    SEPTIC    INFECTION"  435 


PUERPERAL  FEVER  OR  PUERPERAL   SEPTIC  INFECTION 

Puerperal  fever  is  a  disease  resulting  from  infection  during 
labor,  or  the  puerperium,  by  certain  micro-organisms.  It  is  an 
ordinary  surgical  toxaemia  (as  the  term  is  now  generally  known), 
caused  by  the  absorption  of  septic  matters  in  the  wounds  of  the 
utero-genital  canal  produced  during  parturition.  It  may  be  called 
puerperal  infection,  puerperal  septic  infection,  puerperal  scpti- 
ctemia,  puerperal  sepsis,  or  childbed  fever,  a  term  so  commonly 
used  by  the  laity  thirty  years  ago.  No  one  of  these  terms,  how- 
ever, is  correct  in  every  sense. 

The  term  puerperal  fever,  or  febris  puerperarium,  was  first  used 
by  Willis  in  1676,  and  was  in  general  use  in  Great  Britain  and 
America  during  the  first  three-quarters  of  the  nineteenth  century. 
When  through  the  work  of  Semmelweiss,  Pasteur,  Lister,  and  others 
we  began  to  acquire  the  new  ideas  as  to  its  origin,  the  fitness  of  the 
term,  puerperal  fever,  was  called  in  question.  The  late  Fordyce 
Barker,  of  New  York,  believed  that  puerperal  fever  was  a  specific 
disease,  as  definite  in  its  nature  as  erysipelas,  scarlet  fever,  or 
typhoid  fever.  Listerism,  however,  soon  demonstrated  the  incor- 
rectness of  this  contention,  and  the  new  term,  puerperal  septi- 
caemia, was  largely  used. 

Algernon  Temple  was  one  of  the  first  in  Canada  to  deny  the 
specific  entity  of  puerperal  fever,  and  agreed  with  Garrigues  that 
the  term  puerperal  fever  should  be  dropped  and  puerperal  infection 
should  be  substituted. 

Septicsemia  is  not  a  fortunate  term,  because  etymologically  it 
means  a  condition  in  which  septic  matter  circulates  in  the  blood 
throughout  the  whole  body,  and  can  not  therefore  properly  include 
those  numerous  manifestations  of  sepsis  which  are  distinctly  local  in 
character.  This  is  rather  unfortunate,  because,  as  has  been  pointed 
out  by  Garrigues,  it  is  an  improvement  in  so  far  as  it  reminds  us 
of  the  identity  of  puerperal  infection  with  wound  infection. 

While  speaking  on  this  subject  I  shall  not  frequently  use  the 
term  puerperal  fever,  but,  instead,  puerperal  infection.  The  word 
infection  is  not  exactly  suitable,  inasmuch  as  it  is  the  cause  of  the 
condition  we  are  considering,  not  the  condition  itself.  Nor  is  it 
exactly  correct,  because,  with  the  meaning  generally  attached  to  it 
in  connection  with  this  subject,  it  does  not  include  all  puerperal 
infections. 


436  LISTEEISM    AND    OBSTETEICS 


NATURE  OF   PUERPERAL   INFECTION 

It  is  an  infection  caused  by  the  absorption  of  septic  matter  in- 
troduced from  without.  The  doctor  may  introduce  the  poisonous 
germs  at  any  step  of  labor  on  his  finger-tips  or  on  his  instruments. 
The  nurse  may  do  the  mischief  while  assisting  the  doctor  during 
labor  or,  more  frequently,  after  labor.  Twenty-five  or  thirty  years 
ago  childbed  fever  was  said  to  be  caused  by  a  cold.  I  have  often 
heard  this  story.  The  patient  was  doing  well  until  the  third  or 
fourth  day,  when  an  open  window  caused  a  draught  which  struck 
her  and  produced  a  chill.  After  that  she  went  on  from  bad  to 
worse  until  death  ensued  in  a  few  days.  We  know  now  what  that 
chill  meant.  It  was  a  well-pronounced  symptom  of  a  dreadful  but 
preventable  disease — acute  septicaemia — which  has  in  the  past,  in 
a  relentless  way,  claimed  so  many  victims.  One  meets  nothing 
in  his  professional  experience  more  inexpressibly  sad  than  a  death 
from  septicaemia.  The  bright  and  happy  girl  of  yesterday  becomes 
a  bride  to-day.  In  due  course  there  are  indications  that  she  will 
soon  become  a  mother.  Her  friends  take  an  unusual  interest  in  her 
welfare.     Many  years  ago  Oliver  Wendell  Holmes  wrote  as  follows : 

' '  The  woman  about  to  become  a  mother,  or  with  her  new-born 
infant  upon  her  bosom,  should  be  the  object  of  trembling  care  and 
sympathy  wherever  she  bears  her  tender  burden  or  stretches  her 
aching  limbs.  The  very  outcast  of  the  streets  has  pity  upon  her 
sister  in  degradation  when  the  seal  of  promised  maternity  is  im- 
pressed upon  her.  The  remorseless  vengeance  of  the  law  brought 
down  upon  its  victim  by  a  machinery  as  sure  as  destiny  is  arrested 
in  its  fall  at  a  word  which  reveals  her  transient  claim  for  mercy. 
The  solemn  prayer  of  the  liturgy  singles  out  her  sorrows  from  the 
multiplied  trials  of  life,  to  plead  for  her  in  the  hour  of  peril.  God 
forbid  that  any  member  of  the  profession  to  which  she  trusts  her 
life,  doubly  precious  at  that  eventful  period,  should  hazard  it 
negligently,  unadvisedly,  or  selfishly. ' ' 

The  bride  to  whom  I  have  referred,  with  the  help  of  loving 
friends,  makes  preparation  for  the  babe  that  is  to  come.  With  her 
maternal  instincts  developed  to  the  highest  point  she  looks  at  the 
little  shirts,  the  little  petticoats,  the  little  dresses ;  she  thinks  and 
dreams  of  her  unborn  child ;  she  wonders  if  it  will  be  marked,  and 
hopes  it  will  be  "all  right."  At  the  proper  time  the  nurse  and 
doctor  are  summoned.     She  goes  through  the  terrible  ordeal  of 


PUEEPERAL    SEPTIC    INFECTION  437 

labor.  She  hears  with  joy  the  first  cry  of  her  baby.  In  a  short 
time  she  clasps  him  to  her  breast — thankful  and  happy.  Anxious 
friends  ask  many  questions.  The  accoucheur  replies  with  much 
satisfaction,  mother  and  child  both  doing  well.  All  goes  well,  or 
apparejitlij  well,  for  three  or  four  days.  Then  a  cloud  arises,  the 
dread  chill  comes,  a  terrible  poison  fills  the  blood,  and  notwith- 
standing the  efforts  of  the  physician  that  happy  young  mother 
becomes  cold  in  death.  Loving  friends  are  stunned  and  agonized, 
and  an  innocent  motherless  babe  has  lost  its  best  friend.  The 
tragedy  is  sad  enough  in  all  respects;  but,  from  a  professional 
point  of  view,  the  worst  feature  is  that  death  should  not  have 
occurred — it  should  have  been  prevented. 

Infection  may  occur,  however,  in  spite  of  precautions  of  doctor 
and  nurse.  The  dangers  are  so  many,  and  so  little  (apparently) 
may  sometimes  produce  serious  results,  that  the  most  careful  among 
us  can  never  feel  sure  about  the  safety  of  the  patient  until  a  certain 
time  has  elapsed.  Neither  the  man  nor  the  institution  has  yet 
been  discovered  that  sees  not  puerperal  infection.  Let  us  be  rigid 
in  our  examination  of  ourselves  when  we  have  a  patient  sufTering 
from  any  form  of  puerperal  infection,  and  at  the  same  time  chari- 
table in  judging  of  others  under  similar  circumstances. 

HOW  DOES   THE   INFECTION   TAKE   PLACE  ? 

Certain  poisonous  matters  are  introduced  from  without  and  are 
absorbed  by  the  open-mouthed  blood-vessels  and  lymphatics  which 
exist  in  the  wounds  of  the  perinseum,  vulva,  vagina,  cervix,  or  the 
interior  of  the  uterus  (especially  at  the  placental  site) .  The  result 
may  be  simply  a  putrefactive  decomposition,  or  a  mild  septic  in- 
fection with  perhaps  local  purulent  collections,  or  severe  general 
systemic  infection  (acute  septicaemia  which  causes  death  in  from 
two  to  five  days) . 

In  mentioning  the  sites  of  absorption  the  perinseum  is  named 
first,  because  I  think  that  in  a  majority  of  cases  of  puerperal  fever 
the  infection  occurs  through  the  tears  of  the  perinseum  or  pelvic 
floor.  John  Caven  had  this  point  in  view  for  some  years,  and  in 
three  consecutive  cases  found  evidence  post  mortem  to  convince 
him  that  the  torn  perinseum  was  the  site  of  absorption. 

It  is  hard,  of  course,  to  form  a  very  definite  opinion,  but  I  think 
that  in  most  cases  of  severe  or  acute  septicsemia  the  poison  is 


438  LISTEEISM    AND    OBSTETEICS 

absorbed  in  the  tears  of  the  perinseum  or  vulva ;  in  those  of  mild 
septicsemia  or  mixed  infection  the  poison  is  absorbed  in  the  tears  of 
the  vagina  or  cervix ;  in  cases  of  saprsemia  the  poison  is  absorbed 
within  the  uterine  cavity.  It  may  be  asserted,  however,  that  all 
sorts  of  germs  may  be,  and  are  actually,  absorbed  in  wounds  in 
any  or  all  of  these  structures. 

BACTERIOLOGY 

We  have  learned  much  about  bacteriology  in  recent  years  and 
we  hope  to  learn  more  in  the  near  future. 

We  know  that  puerperal  infection  is  produced  by  micro-organ- 
isms generally,  if  not  always,  introduced  from  without.  We  know 
which  are  the  most  common  and  which  are  the  most  virulent  of 
these  organisms.  We  know  that  certain  organisms  are  very  viru- 
lent at  times  and  comparatively  innocent  in  other  cases.  We  know 
that  we  have  sometimes  two  or  more  kinds  of  organisms  in  con- 
nection with  certain  forms  of  sepsis — i.  e.,  mixed  infection.  We 
know  that  we  can,  in  a  large  proportion  of  cases,  if  not  in  all,  by 
certain  aseptic  and  antiseptic  methods,  prevent  the  ingress  of  such 
organisms  and  thereby  avoid  septic  conditions.  We  know  that  we 
have  certain  vital  protecting  forces  in  our  body  which  fight  these 
pathogenic  germs  that  come  in  from  without.  We  know  that  these 
vital  forces  within  our  body  are  frequently  victorious,  and  we  know 
they  are  sometimes  vanquished. 

We  do  not  know  whether  these  pyogenic  organisms  are  them- 
selves the  septic  matter,  or  whether  they  carry  it,  or  whether  in 
certain  cases  they  are  simply  "  accidental  concomitants."  We  do 
not  know  why  certain  organisms  are  more  virulent  than  others. 
We  do  not  know  why  in  some  cases  the  vital  forces  in  our  body  are 
victorious,  while  under  similar  circumstances  at  other  times  they 
are  vanquished.  We  do  not  know  why  certain  organisms  are  ex- 
tremely virulent  in  some  instances  and  comparatively  innocent  in 
others.  We  do  not  know  what  portion  of  the  evil  work  accom- 
plished is  done  by  the  different  organisms  which  we  find  in  mixed 
infections. 

Some  tell  us  that  there  are,  under  ordinary  circumstances, 
pyogenic  organisms  in  both  the  uterine  cavity  and  the  vagina; 
others  say  there  are  none  in  either ;  others  say  there  are  cocci,  in- 
cluding the  streptococci,  which  we  fear  most,  in  the  vagina,  but 
they  are  not  pyogenic  but  rather  saprophytic  in  character. 


PUERPERAL    SEPTIC    INFECTION"  439 

The  subject  will  here  be  simplified  as  far  as  possible,  and 
reference  will  be  made  only  to  facts  related  by  bacteriologists 
which  coincide  with  those  acquired  by  clinical  observation. 

The  specific  microbes  which  produce  puerperal  infection  are 
streptococci,  staphylococci,  colon  bacilli,  gonococci,  and  sapro- 
phytic bacteria. 

Other  microbes  occasionally  found  are  bacillus  diphthcrise, 
diplococcus  pneumoniae,  the  gas  bacillus  of  Welch,  and  the  bacillus 
sepsis. 

In  the  first  place,  it  may  be  well  to  say  a  few  words  about  the 
ordinary  condition  of  the  utero-vaginal  canal  during  pregnancy  and 
the  natural  barriers  which  prevent  the  ingress  of  the  outside  organ- 
isms. No  special  reference  will  be  made  in  this  connection  to  the 
gonococcus,  which  is  different  from  all  other  organisms  in  various 
ways.  I  think  it  never  produces  acute  septicaemia,  but  as  it  gen- 
erally produces  some  serious  effect,  especially  after  labor,  it  will  be 
considered  in  another  chapter. 

Uterus. — Normally  there  are  no  pathogenic  organisms  present 
in  the  uterine  cavity  during  pregnancy.  This  is  positively  stated 
by  such  a  large  number  of  careful  observers,  and  at  the  same  time 
is  in  such  thorough  accord  with  clinical  observations,  that  it  may 
be  accepted  as  a  fact. 

Cervix. — The  plug  of  mucus  found  in  the  cervix  uteri  of  the 
pregnant  woman  is  a  peculiar  and  important  structure  and  is  called 
by  some  the  operculum.  The  plug  is  practically  sterile.  There 
has  been  a  little  confusion  as  to  this  subject  through  differences  of 
detail  in  the  methods  of  examination,  but  it  is  generally  admitted 
that  the  upper  part  of  the  plug  is  absolutely  sterile  and  fills  the 
cavity  so  completely  that  it  prevents  the  passage  of  germs. 

Vagina. — The  vagina  is  practically  sterile,  and  not  only  is  it 
sterile,  but  the  vaginal  secretion  itself  will  destroy  certain  germs, 
especially  the  staphylococci.  That  is  to  say,  if  these  germs  are 
introduced  within  the  vagina  they  will  be  destroyed  within  a 
limited  time.  This  quality  of  the  secretion  is  due  to  the  pres- 
ence of  what  is  called  the  vaginal  bacillus,  which  keeps  the  secre- 
tion acid. 

Vulva. — There  is  a  different  condition  in  the  neighborhood  of 
the  vulva.  In  a  large  proportion  of  cases  pyogenic  bacteria  exist 
at  the  vulvar  orifice,  and  these  organisms,  situated  thus  superfi- 
cially,  are  dangerous  during  labor  and  the  puerperium.     A  very 


440  LISTEEISM    AND    OBSTETRICS 

important  difference  in  the  condition  is  found  after  labor.  Within 
a  short  time  the  acid  secretion  of  the  vagina  becomes  alkaline 
from  the  destruction  of  the  bacilH  vaginse  by  the  lochia.  Any- 
septic  organisms  may,  under  the  changed  conditions,  cause  much 
mischief,  especially  during  the  first  three  days  after  labor.  If 
everything  has  gone  on  favorably  for  three  or  four  days  the 
wounds  will  be  healthy  and  as  a  consequence  will  be  covered  with 
granulations.  These  granulations,  as  before  mentioned,  are  a 
great  barrier  to  absorption,  and  therefore  if  there  is  no  infection 
before  the  formation  of  the  granulations  the  danger  of  serious  or 
acute  septicsemia  thereafter  is  almost  nil. 


VARIETIES  OF  PUERPERAL  INFECTION 

It  is  difficult  to  name  specifically  the  different  varieties  of  puer- 
peral infection.  It  seems  convenient  to  speak  first  of  two  varieties 
— that  is,  saprsemia,  or  putrid  intoxication,  and  septicaemia,  or  in- 
fection by  pyogenic  germs.  Unfortunately  the  term  saprsemia, 
which  was  first  used  by  Matthews  Duncan,  has  been  applied  to 
so  many  forms  of  infection  that  much  confusion  has  arisen. 

Smyly,  JeUett  and  Lyle,  of  the  Rotunda,  beheve  that  organ- 
isms which  were  at  first  saprophjrtic  and  thus  able  to  five  upon 
dead  matter  only,  may  under  certain  conditions  become  parasitic 
and  thus  able  to  exist  on  living  tissues.  According  to  their  views, 
therefore,  saprsemia  may  be  both  saprophytic  and  parasitic  (or 
septic).     This  is,  I  think,  going  beyond  what  Duncan  intended. 

In  sepsis  we  may  have  only  one  form  or  one  kind  of  pyogenic 
germ,  or  we  may  have  two  or  more  kinds  of  such  germs.  In  cer- 
tain cases  the  germs  are  less  virulent  and  cause  results  less  serious ; 
in  other  cases  the  germs  are  very  virulent  and  cause  death  rapidly ; 
in  other  cases  there  is  severe  poisoning,  the  symptoms  of  which 
may  become,  to  a  certain  extent,  chronic ;  and  under  such  circum- 
stances metastatic  abscesses  may  occur. 

In  considering  the  various  forms  of  septic  infection  that  may 
arise  it  is  advisable  to  use  a  classification  which  is  simple  in  char- 
acter from  a  clinical  standpoint;  but  while  the  clinical  aspects 
should  be  kept  in  view,  it  should  be  founded  on  a  bacteriological 
basis.  Puerperal  infection  includes  the  following:  (1)  saprsemia, 
(2)  mild  septicsemia,  (3)  mixed  infection,  (4)  acute  septicaemia,  and 
(5)  pysemia. 


PUEKPEUAL    SEPTIC    INFECTJON 


441 


Sapraemia. — Saprconiia  is  a  condition  caused  by  the  absorption 
of  the  products  of  decomposition.  The  bacteria  concerned  in  the 
process  are  called  saprophytic  organisms,  which  live  on  dead 
matter,  such  as  blood  clots,  portions  of  placenta,  or  membranes. 

Mild  Septicaemia. — Septicaemia  of  any  sort  or  degree  is  a  dis- 
eased condition  produced  by  the  absorption  of  the  products  of 


F. 

107' 

106^ 
105° 
104" 
103° 
102° 
101° 
100/ 
99° 
98° 
97° 

11 

o-^ 

■^^^ 

,/ 

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-•— 

-•-- 

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.  A 

V 

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y     ^ 

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M 
Pulse 

E 

100 

102 

108 

106 

98 

104 

98 

98 

90 

88 

90 

84 

80 

80 

108 

111 

112 

114 

112 

108 

120 

100 

96 

96 

98 

96 

88 

90 

Fig.    155. — Abnormal,    Involution,    Temperature    and    Pulse    Rate,    Mild 

Septicemia,  with  Subinvolution. 

Temperature  rose  to  105.4  after  curettement  on  seventh  day.     The  curettement 

was  probably  unnecessary  and  harmful. 


pathogenic  bacteria.  It  is  convenient  for  clinical  purposes  to 
speak  of  a  mild  septicaemia  as  opposed  to  a  severe  or  acute  sep- 
ticemia. 

The  clinical  differences  between  the  two  are  well  marked ;  the 
bacteriological  differences  between  the  two  are  not  so  well  marked 
so  far  as  we  understand  the  subject  at  present. 

Mixed  Infection. — Mixed  infection  is  produced  by  the  ingress 
of  two  or  more  varieties  of  pathogenic  germs.  We  might,  for  in- 
stance, find  in  the  system  streptococci  with  a  few  staphylococci  and 
colon  bacilli.  This  would  be,  in  a  sense,  mixed  infection,  but  it 
might  be  that  the  streptococci  did  all  the  damage,  while  the  staphy- 
lococci and  colon  bacilli  had  little  or  no  effect.  From  a  clinical 
standpoint  this  should  not  be  considered  a  mixed  infection. 


442  LISTEKISM    AND    OBSTETEICS 

In  another  case  a  patient  might  be  ill  for  some  time  with  per- 
haps peritonitis,  produced  chiefly  or  altogether  by  streptococci, 
metastatic  abscesses  in  various  organs  produced  by  staphylococci, 
and  perhaps  the  colon  bacilh  might  have  a  certain  effect  on  each 
of  these  separate  processes  or  conditions.  This  would  be  from  a 
clinical  point  of  view  a  case  of  mixed  infection. 

Acute  Septicaemia. — Acute  septicaemia  (or  acutest  septicaemia 
of  Garrigues)  is  that  virulent  form  of  septic  poisoning  which  causes 
death  in  from  two  to  five  days.  In  this  variety  of  sepsis  the  germs 
are  so  powerful  for  evil  that  they  produce  their  fatal  effects  in  a 
short  time.  The  nerve  centers  are  completely  overpowered,  and 
death  comes  so  rapidly  that  there  is  not  sufficient  time  for  the 
development  of  the  ordinary  gross  pathological  conditions  which 
are  found  after  death  from  the  milder  infections. 

Pyaemia. — Pyaemia  is  a  form  of  toxaemia  in  which  living  bac- 
teria are  carried  in  the  blood  currents  to  distant  tissues,  where  they 
grow,  multiply,  and  produce  abscesses.  It  is  probable  that  these 
bacteria  are  first  lodged  in  clots  and  gain  entrance  to  the  general 
circulation  as  the  clots  break  down.  Pyaemia  has  never  been  con- 
sidered a  scientific  term,  and  is  not  at  all,  as  its  etymology  imphes,. 
a  condition  of  pus  in  the  blood.  It  has  been  retained  chiefly  on 
account  of  its  clinical  value  as  referring  to  a  disease  with  formation 
of  abscesses  in  various  parts  of  the  body.  (In  other  words,  it  may 
be  considered  a  subacute  or  chronic  septicaemia  with  the  forma- 
tion of  the  abscesses  before  referred  to.)  The  germs  which  pro- 
duce the  infection  are,  in  the  majority  of  instances,  those  which 
produce  acute  or  severe  septicaemia. 

There  is  another  classification  of  less  importance:  (1)  Hetero- 
genetic  infection,  when  the  poison  is  introduced  from  without. 
(2)  Autogenetic  infection,  when  the  poison  is  generated  within 
the  body. 

There  has  been  a  great  deal  of  discussion  on  this  subject  in  the 
past.  The  importance  of  the  autogenetic  infection  was  at  one 
time  greatly  exaggerated.  Many  authors  spoke  very  strongly  on 
the  subject.  Chalmers  Cameron  considered  that  the  doctrine  of 
auto-infection,  as  commonly  expounded,  could  do  nothing  but 
harm  and  therefore  should  be  absolutely  condemned. 

Obstetricians  should  in  practice  consider  that  in  all  cases  the 
poison  comes  from  without,,  although  it  may  be  admitted  that  auto- 
infection  does  occasionally  occur. 


rUERPEEAL    SEPTIC    INFEC'IHOX  443 


PATHOLOGY 

After  a  consideration  of  the  bacteriology  of  septic  infection  one 
can  understand,  to  a  certain  extent  at  least,  the  reasons  for  the 
great  variety  of  lesions  which  are  produced  in  the  body  by  the 
microbes  or  their  products.  The  following  are  the  principal  types 
of  pathological  conditions  which  are  found : 

Poisoning.— TAe  'profound  poisoning  which  overpowers  the 
nerve  centers  causes  death  so  quickly  that  there  are  no  gross  lesions. 
There  are,  however,  as  pointed  out  by  Garrigues,  traces  of  lym- 
phangitis or  phlebitis,  swelhng  of  the  connective  tissue,  and  a  little 
bloody  fluid  in  the  different  cavities.  The  abdominal  organs  are 
large,  soft,  and  friable,  the  microscope  showing  their  cells  to  be  in 
the  condition  called  cloudy  swelling;  the  blood  is  thin,  dark,  and 
only  slightlj^  coagulable. 

Vulvitis  and  Vaginitis. — In  connection  with  inflammation  of  the 
vulva  and  vagina,  one  of  the  most  important  conditions  is  the  so- 
called  diphtheritic  ulcer,  which  may  be  found  on  the  surface  of  the 
tears  about  the  vulva  and  in  the  vagina.  In  almost  all  cases,  if 
not  in  all,  such  an  ulcer  has  nothing  in  common  with  diphtheria 
except  its  external  appearance.  Puerperal  vaginitis  may  there- 
fore occur  in  two  forms :  either  inflammation  where  a  certain  por- 
tion of  the  vagina  is  covered  by  this  pseudo-diphtheritic  mem- 
brane, or  a  general  inflammation  when  the  mucosa  becomes  thick, 
soft,  red,  and  covered  with  pus  (Williams). 

Endometritis. — The  endometrium  is,  in  a  large  proportion  of 
cases  (some  say  in  the  majority),  an  important  seat  of  the  puer- 
peral infection.  The  septic  endometritis  thus  induced  varies 
greatly  according  to  the  character  of  the  organisms  and  the  vary- 
ing virulence  of  such  organisms.  When  produced  by  virulent 
streptococci  or  staphylococci  the  changes  are  comparatively 
slight,  as  before  indicated.  On  the  other  hand,  when  produced 
by  putrefactive  organisms,  and  perhaps  by  the  colon  bacilli,  the 
local  lesions  are  much  more  apparent.  The  infection  may  be 
limited  to  the  placental  site  or  it  may  be  spread  over  the  entire 
mucosa.  When  confined  to  the  placental  site  the  organisms  usuall}^ 
pass  into  the  thrombi ;  when  extending  over  the  whole  inner  surface 
of  the  uterus  the  local  effects  are  much  more  marked.  A  great 
deal  of  necrotic  material  is  produced,  dirty  and  yellowish  green 
in   color.     Ulcerated   surfaces  coated  with  fibrin  ("diphtheritic 


444  LISTEEISM    AND    OBSTETEICS 

patches  ")  are  sometimes  found.  In  cases  of  infection  due  to  the 
invasion  of  virulent  streptococci,  or  staphylococci,  there  is  usually 
little  or  no  odor  from  the  lochia;  but  in  cases  of  invasion  by 
saprophytic  organisms  or  the  colon  bacilli  there  is  a  very  offen- 
sive odor  from  the  discharges. 

Metritis. — Various  forms  of  metritis  are  hkely  to  exist  in  con- 
nection with  the  different  forms  of  infection.  There  may  be  a 
simple  inflammatory  condition,  in  which  the  walls  are  thickened, 
soft  and  friable,  or  a  more  serious  form  called  putrescent  metritis. 
In  the  latter  form  the  uterus  is  large,  although  the  walls  may  be 
thin.  There  is  considerable  destruction  of  tissue,  and  irregular 
cavities  are  found  filled  with  a  dark-colored  pulp  or  with  puru- 
lent fluid. 

Parametritis  is  inflammation  of  tissues  in  the  vicinity  of  the 
uterus.  It  is  usually  caused  by  the  passage  of  the  organisms 
from  the  uterus,  especially  from  a  lacerated  cervix,  through  the 
lymphatics  to  the  peri-uterine  connective  tissue.  According  to 
Whitridge  Wilhams,  the  first  effect  is  a  marked  inflammatory 
oedema  with  very  little  or  no  suppuration.  In  mild  cases  the 
process  is  stopped  here ;  in  more  severe  cases  the  infection  spreads 
to  the  surrounding  connective  tissue  and  causes  the  formation  of 
abscesses. 

Salpingitis. — Inflammation  of  the  Fallopian  tubes  is  quite 
common,  and  is  generally  due  to  an  extension  of  the  process  from 
the  uterine  cavity,  but  sometimes  is  probably  due  to  infection 
through  the  lymphatics. 

Oophoritis. — Less  commonly  we  have  septic  inflammation  of  the 
ovaries,  probably  due  in  most  cases  to  infection  through  the  lym- 
phatics. We  are  told,  however,  that  in  a  certain  number  of  cases 
it  may  be  due  to  direct  infection  of  a  ruptured  folHcle  by  means  of 
the  peritonitic  exudation. 

Peritonitis. — Peritonitis  is  such  a  common  affection  in  puer- 
peral fever  that  at  one  time  the  two  terms,  puerperal  fever  and 
puerperal  peritonitis,  were  thought  to  be  synonymous.  The  in- 
flammation may  be  local — that  is,  confined  to  the  pelvis ;  or  gen- 
eral— that  is,  extending  over  the  whole  abdomen.  It  is  generally 
due  to  infection  by  the  organisms  that  pass  from  the  interior  of  the 
uterus  through  the  lymphatics  to  its  peritoneal  surface.  It  may 
rarely  be  due  to  infection  by  pus  from  the  Fallopian  tubes  or  by 
rupture  of  parametric  or  ovarian  abscesses.     The  inflammation 


PUEEPERAL    SEPTIC    INFECTION  445 

may  be  plastic  or  purulent.  Fluid  is  found  in  the  peritoneal  cavity 
which  may  be  serous  or  purulent,  which  often  resembles  milk. 

Pyaemia. — This  is  probably  due  in  most  cases  to  the  infection 
of  the  thrombi  at  the  placental  site,  followed  by  inflammatory 
changes  in  the  veins.  When  the  thrombi  break  down  small  par- 
ticles are  carried  to  various  parts  of  the  body,  giving  rise  to  the 
abscesses  before  referred  to.  Such  abscesses  may  be  found  in  all 
the  internal  organs  and  in  synovial  cavities. 

Phlegmasia  Alba  Dolens. — This  is  a  peculiar  form  of  infection, 
in  which  there  is  an  extension  of  the  infective  process  to  the  tissues 
surrounding  large  blood-vessels,  generally  of  the  lower  extremi- 
ties, but  sometimes  those  of  the  upper  extremities,  through  the 
lymphatics.  Thromboses  then  occur  in  these  large  vessels  due  to 
the  lymphatic  involvement. 


SYMPTOMS   OF  PUERPERAL  INFECTION 

One  can  easily  understand  the  vast  importance  of  the  ques- 
tion of  diagnosis  of  puerperal  infection.  An  early  recognition  of 
the  symptoms  will  enable  the  accoucheur  to  treat  promptly,  and 
in  a  large  proportion  of  cases  successfully,  this  dread  disease. 
The  descriptions  of  the  symptoms  of  septic  infection  given  in  the 
majority  of  our  text-books  are  unsatisfactory  and  to  some  extent 
misleading. 

The  following  paragraph  from  one  of  the  best  treatises  on 
obstetrics  may  be  taken  as  an  illustration : 

"  In  the  cases  of  septic  endometritis  everything  goes  smoothly 
for  the  first  three  or  four  days  of  the  puerperium,  when  our  patient, 
who  thus  far  has  done  perfectly  well,  suddenly  experiences  more  or 
less  malaise,  possibly  has  a  headache,  and  toward  the  end  of  the 
third  or  fourth  day  a  chill,  after  which  the  temperature  rises  to 
103°  or  more.  Generally  the  chill  occurs  but  once,  while  the  tem- 
perature remains  constantly  elevated.'' 

This  is  wrong ;  things  never  go  "  smoothly  for  the  first  three  or 
four  days  of  the  puerperium"  in  a  case  of  infection. 

On  the  other  hand,  we  have  had  correct  descriptions  from 
authors  on  the  Continent.  Ferre  some  years  ago  described  very 
clearly  what  he  called  the  premonitory  symptoms. 

Shght  elevation  of  temperature  once  or  twice  daily,  and  usually 
in  the  evening ;  pulse  SO  or  more,  especially  in  the  morning,  when 


446 


LISTERISM    AND    OBSTETEICS 


the  temperature  is  not  yet  raised ;  relative  or  absolute  insomnia ; 
headache,  at  first  intermittent  and  slight;  vague  impressions  of 
cold,  not  usually  a  distinct  rigor. 

The  following  quotation  from  a  very  able  but  modest  little 
pamphlet  entitled  ''Chnical  Observations  on  Two  Thousand  Ob- 
stetric Cases,"  published  in  1898  by  Porter  Mathew,  of  London, 

formerly  Resident  Obstetric 
Officer  at  St.  Mary's  Hospital 
and  Queen  Charlotte  Hospital, 
is,  I  think,  in  all  respects 
correct. 

''Any  one  who  reads  or 
hears  of  fatal  cases  of  septicae- 
mia must  be  very  much  struck 
with  the  fact  that  the  account 
of  the  case  is  invariably  that 
progress  was  perfectly  satisfac- 
tory until  the  third  or  fourth 
day,  or  later,  as  the  case  may 
be,  when  the  patient  developed 
a  rigor  or  high  temperature, 
and  then  treatment  was  started 
but  too  often  without  avail. 
This  would  lead  the  unwary  to 
imagine  that  the  onset,  like 
many  of  the  specific  fevers,  was  of  a  very  sudden,  almost  fulminat- 
ing, character.  It  is  a  curious  fact,  however,  that  though  I  have 
looked  through  twelve  thousand  puerperal  temperature  charts  I 
can  not  find  a  single  instance  of  perfectly  satisfactory  progress  fol- 
lowed by  septicffimia.  There  are  always  present  premonitory  signs 
and  symptoms  of  mischief  brewing  before  the  rigor,  which  by  so 
many  is  looked  upon  as  the  beginning  of  the  illness.  These 
symptoms  are  loss  of  appetite,  insomnia,  a  feeling  of  fatigue  or 
lassitude,  low  spirits  with  tendency  to  tears,  perspiration,  and 
frontal  headache.  The  signs  are  a  progressive,  step-like,  or  irreg- 
ular rise  of  temperature,  with  marked  morning  remission  and 
evening  exacerbation,  a  gradual  rise  in  pulse  rate  with  marked 
remission  at  night,  with  or  without  tenderness,  especially  local 
tenderness  of  the  uterus,  and  decomposition  of  the  lochia  in  the 
uterus.     Some  of  these  signs  or  symptoms,  usually  both,  were 


Fig.  156. — Louis  Pasteur. 


PUERPEEAL    SEPTIC    INFECTIOK 


447 


invariably  present,  but  in  a  few  cases  the  only  apparent  abnormal 
condition  was  the  temperature,  especially  the  gradual  increasing 
rise  at  night.  Evidently,  then,  if  the  development  of  septicaemia 
is  preventable  it  is  to  these  early  symptoms  we  must  look  for  warn- 
ing, and  if  any  treatment  be  of  avail  its  success  will  be  the  more 
enhanced  the  earher  the  recognition  of  these  premonitory  signs." 

We  have,  then,  two  sets  of  symptoms :  the  early  or  premonitory, 
on  the  one  hand,  and  the  ordinary  symptoms  on  the  other.  The 
directions  as  to  watchful  care  of  the  patient  during  the  early  days 
of  the  normal  puerperium  may  be  repeated  to  some  extent. 

On  the  second  day  study  the  appearance  of  the  patient  care- 
fully. Has  she  a  happy,  restful  aspect  of  countenance,  or  has  she 
a  worried  expression?  Does  she  appear  to  be  quiet  and  comfort- 
able, or  restless  and  uncomfort- 
able? You  make  your  inquiries 
from  the  patient.  Has  she  felt 
well  since  you  last  saw  her?  She 
may  say,  ''Yes,  quite  well." 
That  will  be  satisfactory.  She 
may  say,  "Yes,  doctor,  I  feel 
pretty  well,  but  I  have  a  slight 
headache.  I  think  it  arises  from 
the  fact  that  I  did  not  sleep 
very  well.  I  think  I  couldn't 
sleep  because  the  baby  was  trou- 
blesome and  cried  a  good  deal." 
This  answer  is  very  unsatisfac- 
tory. In  it  there  are  two  of 
the  most  constant  premonitory 
symptoms  of  infection:  insomnia 
and  headache.  Continue  inqui- 
ries with  reference  to  both  these 
features,  and   also   as  to  whether 

she  feels  tired.  Find  out  if  she  has  any  perspiration.  With 
reference  to  the  headache,  find  out  where  it  is — that  is  to  say,  is  it 
frontal? 

What  is  the  pulse  rate  ?     Is  it  under  or  over  80?     What  is  the 
temperature?     This  may  be  increased  to  a  slight  degree,  of  course, 
without  evil  results.     A  temperature  of  100  would  in  the  majority 
of  cases  not  be  so  serious  a  symptom  as  insomnia  with  headache. 
30 


Fig.  157. — Oliver  Wendell 
Holmes. 


448 


LISTEEISM    AND    OBSTETEICS 


Then  get  all  the  information  possible  from  the  nurse  as  to 
all  these  points  which  you  have  already  inquired  about,  and 
especially  as  to  the  quantity  and  quality  of  the  lochia.     Pursue 


107° 
106° 
105° 

104° 
103° 

102° 
101° 
100° 
99° 
98° 
97° 

Midi 

ight 

■ 

^. 

n 

\ 

\ 

It 

h 

f\ 

\ 

V 

\ 

i 

\ 

1 

V 

V 

\ 

\ 

\ 

3 

A.M. 

M 
Pulse 

E 

9U 

88 

96 

100 

102 

110 

120 

114 

98 

96 

108 

100 

112 

140 

160 

? 

Resp. 

■    E 

23 

24 

32 

26 

34 

66 

58 

68 

as 

24 

28 

32 

34 

44 

54 

54 

Fig.   158. — Patient  Attended  by  a  Midwife;  seen  by  Dr.  William 
Britton,  Five  Days  after  Labor;  Septicaemia,  Pneumonia. 

Highest  and  lowest  during  each  twenty-four  hours.     On  the  day  before  death  tem- 
perature rose  10°  between  3  a.  m.  and  midnight.     Died  at  4  a.  m.  next  day. 


a  similar  method  of  investigation  during  the  third,  fourth,  and 
fifth  days. 

In  speaking  of  ordinary  symptoms  there  is  considerable  diffi- 
culty in  giving  anything  like  a  definite  classification.  In  speaking 
of  the  pathological  anatomy  reference  was  made  to  the  various 
conditions  found  in  the  different  parts  of  the  body.  The  symp- 
toms will  naturally  vary  according  to  the  parts  of  the  body 
infected.  Lesions  which  are  localized  will  naturally  give  rise  to 
symptoms  very  different  from  those  where  the  whole  system  is  in- 
fected. Differences  in  the  character  or  in  the  virulence  or  in  the 
number  of  the  infective  organisms  will  also  cause  great  variations 
in  the  symptoms. 


PUERPEEAL    SEPTIC    INFECTION" 


449 


ORDINARY    SYMPTOMS 

Smyly's  admirable  aphorisms  are  interesting  and  useful. 

If  a  patient  with  a  high  temperature  looks  well,  sleeps  well,  and 
says  she  is  well,  she  is,  at  any  rate,  not  septic. 

If  a  patient  with  a  high  temperature  looks  very  ill,  sleeps  ver}' 
badly,  and  says  she  feels  ill,  she  generally  is  very  ill. 

If  a  patient  with  a  high  temperature  looks  very  ill,  sleeps  very 
badly,  but  says  she  is  very  well,  she  will  probably  die. 

Rapid  Pulse. — The  pulse  rate  is  the  one  symptom  which  is  im- 
portant above  all  others.  It  is,  in  a  large  proportion  of  cases,  the 
most  certain  indicator  of  the  condition  of  the  system.  For  ex- 
ample, the  pulse  rate  on  the  second  day  is  90,  and  steadily  advances 


F. 

107" 

106° 
105" 
104° 
103' 
102" 
101° 
100° 

7 

97° 

n 

§3,5 

•^ 

-^1 

,A^ 

\ 

/ 

> 

^- 

"^H 

V" 

\ 

A 

K 

A 

A 

f 

^/ 

V   ^ 

•*.^ 

/ 

/^ 

y 

\i 

V  s 

\A 

K 

v 

V^ 

.A 

uA 

A 

>   / 

V 

y'- 

\ 

V 

M 
Pulse 
E 

104 

116 

96 

91 

90 

92 

90 

8i 

88 

90 

88 

82 

80 

78 

108 

120 

112 

118 

108 

104 

96 

90 

90 

92 

92 

88 

86 

96 

Fig.  159. — Abnormal  Involution  Line. 

Case  went  "  queer  "  for  a  few  days  from  unknown  causes.     Good  recovery  followed 
eliminative  treatment. 


until  the  fifth  day,  when  it  is  140.  Without  having  any  regard  to 
other  symptoms  it  may  be  stated  that  this  patient  will  surely  die. 
Increased  Temperature. — An  abnormal  temperature  is  also  an 
important  symptom,  especially  as  it  is  likely  to  be  one  of  the  first 
to  be  observed.  A  very  high  temperature  or  a  very  low  tempera- 
ture is  a  serious  sign ;  irregular  fluctuations  in  the  temperature  in- 
dicate a  serious  condition,  but  it  may  happen  that  the  temperature 


450 


LISTERISM    AND    OBSTETRICS 


at  a  very  critical  period  is  normal,  as,  for  instance,  when  it  is  pass- 
ing from  an  abnormally  high  to  an  abnormally  low  degree — that  is, 
one  may  happen  to  take  the  temperature  while  it  is  crossing  the 
normal  line.     As  before  indicated,  there  may  be  a  slight  rise  of 


F. 

107° 

106" 
105" 
104° 
103° 
103° 
lOl' 
100° 
99° 

r\ 

^■^ 

> 

» 

\ 

V. 

h 

i\ 

■^f 

~*N^ 

/ 

\ 

V^ 

/ 

V 

L 

y"^ 

s,-. 

i 

A 

V 

v-^ 

-•■''^ 

!=•=»- 

r*~*~- 

.^ 

.»— • 

97° 

M 
Pulse 
E 

70 

C2 

7i 

78 

70 

68 

68 

68 

66 

68 

61 

62 

61 

m. 

61 

70 

90 

78 

70 

72 

70 

68 

66 

61 

66 

68 

68 

Fig.  160. — Slight  Influenza;  no  Complications;  Good  Recovery. 


temperature,  the  so-called  reactionary  temperature,  which  may  be 
considered  physiological,  at  least  not  pathological.  There  may  be 
also  a  rapid  pulse,  increased  temperature  from  other  causes  some 
of  which  have  been  discussed,  such  as  influenza,  indigestion,  gen- 
eral malaise,  etc.  It  is  hard  to  give  a  definite  rule,  but  it  may  be 
stated  in  a  general  way  that  when  the  temperature  rises  to  101°  or 
more  and  remains  there  for  some  time  the  patient  is  in  a  serious 
condition. 

Rigor. — A  rigor,  or  chill  (so  called),  when  due  to  sepsis,  is  a 
very  serious  symptom.  The  chill  which  the  patient  has  very  com- 
monly immediately  after  delivery  is  not  at  all  serious.  There  may 
be  a  very  pronounced  rigor  in  certain  cases  from  very  slight  causes, 
especially  emotional  causes.  However,  any  rigor  occurring  one  or 
more  days  after  delivery  should  be  considered  serious.  It  is  well 
to  take  the  more  serious  view,  although  one  may  at  the  same  time 
have  the  slighter  causes  in  his  mind.  In  any  case  careful  inves- 
tigation should  be  made. 


PUERPERAL    SEPTIC    INFECTION 


451 


Pain  and  Tenderness. — Pain  in  and  about  the  parturient  canal 
is  a  conunon  symptom.  I'ain  and  tenderness  over  the  abdomen 
are  also  common  symptoms.  We  are  apt  to  find  such  pain  and 
tenderness  especially  when  there  is  general  peritonitis.  However, 
one  may  have  general  septic  peritonitis  with  very  little  or  abso- 
lutely no  pain ;  and,  unfortvmatcly,  under  such  circumstances  the 
absence  of  the  pain  and  tenderness  is  a  very  bad  sign,  and  prob- 
ably points  to  that  terrible  condition  known  as  acutest  septicasmia. 

Low  Delirium. — There  is  nothing  special  about  the  character 
of  the  low  delirium,  which  is  similar  to  that  which  we  find  in 
many,  or  all,  diseases  accompanied  by  high  temperature  and 
great  debility. 

Expression  and  Color  of  Face. — There  is  generally,  or  always, 
some  change  in  the  expression  of  the  face  and  also  in  its  color. 


107° 

106° 

105° 

1M° 

103° 

102° 

101° 

100° 

99° 

98/ 

97° 

1 

i 

5 

V^ 

o 

^". 

X 

6 

\ 

\ 

h 

"--. 

Va 

A 

\  A 

A 

A 

V.A 

1    A 

.    .^ 

u/^ 

n/ 

VN 

■i 

V 

V 

\^ 

^> 

A 

V 

V 

V 

V 

-^ 

^' 

M 
Pulse 

E 

84 

78 

76 

70 

84 

74 

80 

112 

96 

80 

78 

70 

70 

68 

88 

80 

84 

76 

88 

78 

96 

108 

100 

84 

80 

72 

7d 

78 

Fig.   161. — After   Delivery  of  Placenta,   Fundus    Ascended. 
Clots  Expelled,  Fundus  Immediately  Descended. 


Temperature  rose  on  eighth  day  from  acute   indigestion, 
caused  fall  of  temperature. 


A  dose  of  castor  oil 


The  countenance  is  anxious  and  sometimes  the  color  is  sallow. 
There  is,  in  many  cases  of  acute  septicaemia,  a  peculiar  expression 
which  I  can  not  describe,  but  which  when  once  seen  is  generally 
remembered.     The  face  is  pinched  and  ghastly,  with  frequently  a 


452  LISTEEISM    AND    OBSTETRICS 

bright  red  spot  on  each  cheek  and  an  unnaturally  bright  expression 
in  the  eyes.  After  a  time  the  face  is  covered  with  cold  drops  of 
perspiration  and  the  hps  become  blue. 

Disorders  of  the  Stomach  and  Intestinal  Canal. — There  is  gen- 
erally derangement  of  the  stomach,  as  shown  by  loss  of  appetite 
and  vomiting;  also  of  the  intestinal  canal,  as  shown  by  diarrhoea. 
Vomiting  of  coffee-ground  substances  is  an  especially  serious 
symptom. 

Changes  in  the  Lochia. — Sometimes  the  lochia  become  offen- 
sive. This  indicates  sapra^mia,  although  the  lochia  may  become 
slightly  offensive  simply  by  retention  in  the  vagina.  In  other 
cases  the  lochia  may  be  suppressed.  This  is  generally  an  indica- 
tion of  sepsis.  There  is,  however,  a  very  serious  septic  condition 
without  suppression  of  the  lochia,  and  sometimes  in  such  cases  the 
lochia  may  not  be  in  the  least  offensive. 

Reference  "mil  now  be  made  briefly  to  some  of  the  varieties 
of  infection  which  have  special  characteristics. 

Saprsemia.^ — Rapid  pulse  and  rise  of  temperature  occur  in  from 
the  second  to  fifth  day  after  labor.  The  symptoms  appear  some- 
what gradually,  at  the  same  time  the  lochia  become  offensive. 
With  these  signs  we  have  the  ordinary  symptoms,  before  described, 
of  headache,  insomnia,  and  weaHness.  We  do  not  consider  this 
a  very  serious  condition  because  we  believe  that  we  can  cure  it. 
One  should,  however,  never  forget  that  sapraemia  may  be  followed 
by  the  more  serious  condition  of  septic  infection. 

Mild  Sepsis. — The  symptoms  of  mild  sepsis  include  all  those 
which  were  described  as  premonitory;  and  in  addition  many  of 
those  termed  ordinary.  Pain  and  tenderness  are  generally  prom- 
inent symptoms  and  depend  on  the  parts  infected.  In  many 
cases  the  system  is  able  to  throw  off  the  poison,  in  other  cases 
localized  inflammations  occur,  which  may  end  in  resolution  or  in 
suppuration.  In  such  cases  we  have  the  ordinary  symptoms 
associated  with  such  inflammatory  processes.  The  most  common 
varieties  of  localized  inflammation  caused  by  mild  sepsis  are  pelvic 
celluUtis  and  pelvic  peritonitis. 

Parametritis  or  Pelvic  Cellulitis. — The  physical  signs  of  in- 
flammation of  the  pelvic  connective  tissue  generally  appear  about 
the  fourth  or  fifth  day,  or  two  or  three  days  after  the  commence- 
ment of  the  ordinary  premonitory  signs  of  sepsis,  or  about  one  day 
after  the  onset  of  the  more  serious  symptoms.     There  is  an  effusion 


PUEEPERAL    SEPTIC    INFECTION  453 

of  lymph  nearly  always  confined  to  one  side  of  the  pelvis  (gener- 
ally the  left  side) ;  this  causes  a  swelling,  which  can  easily  be  felt 
by  vaginal  examination,  and  which  is  frequently  so  large  that  it 
pushes  the  uterus  toward  the  opposite  side.  When  the  swelhng 
reaches  the  pelvic  wall  it  follows  the  latter  closely,  while  in  peri- 
tonitis the  fingers  may  be  inserted  between  the  swelling  and  the 
bones  (Garrigues).  When  suppuration  takes  place  we  get  what 
is  commonly  known  as  pelvic  abscess.  The  lymph  effusion  may 
extend  from  the  broad  Ugaments  to  the  connective  tissue  about 
the  psoas  muscle,  or  beneath  the  parietal  peritonsBum,  or  along  the 
round  ligaments  to  the  inguinal  canal,  or  from  the  utero-sacral 
ligaments  to  the  connective  tissue  about  the  rectum.  Dakin  says 
the  effect  of  such  spreading  is  sometimes  confusing,  especially 
when  the  cellulitis  has  disappeared  from  the  pelvis,  leaving  masses 
of  inflamed  tissue  in  remote  parts  of  the  abdomen. 

During  the  process  of  absorption  of  an  ordinary  inflammatory 
effusion  in  the  broad  ligament,  the  contraction,  which  usually 
occurs  in  resolving  inflammatory  deposits,  causes  the  uterus  to  be 
drawn  toward  the  side  originally  affected.  Thus  we  are  likely  to 
find  during  the  progress  of  the  case  the  uterus  at  first  pushed 
toward  the  right  side  of  the  pelvis,  and  after  a  time  drawn  close 
to  the  left  side,  or  occasionally  vice  versa. 

Pelvic  Peritonitis. — The  physical  signs  of  localized  inflammation 
of  the  pelvic  peritonaeum  generally  appear  about  one  or  two  days 
later  than  those  of  pelvic  celluhtis.  This  can  be  detected  in  those 
cases  where  the  patient  had  both  parametritis  and  peritonitis. 
The  premonitory  and  actual  symptoms  of  sepsis  are  generally 
well  pronounced  some  days  before  the  inflammatory  products  can 
be  detected.  These  symptoms  are  to  some  extent  similar  to  those 
due  to  parametritis,  but  in  peritonitis,  even  when  fairly  well 
locaUzed,  the  initial  chill  is  more  common  and  more  protracted. 
This  is  followed  by  great  pain  and  tenderness  in  the  lower  abdo- 
men, with  rapid  pulse  and  high  temperature.  It  is  frequently 
hard  to  draw  the  line  between  general  and  local  peritonitis,  and 
for  some  days  it  may  be  impossible  to  decide  in  a  particular  case. 

After  a  time  (generally  seven  to  twelve  days  after  labor)  the 
inflammatory  exudate  in  the  pelvis  and  lower  abdomen  may  be 
detected  by  internal  and  external  examination.  The  mass  is  not 
usually  unilateral  as  in  parametritis,  and  is  situated  behind  in 
Douglas's  pouch  and  not  on  one  side  of  the  uterus.     The  exudate 


454  LISTEEISM    AND    OBSTETEICS 

gradually  appears  to  surround  the  uterus,  causing  a  fixation  of  that 
organ  similar  to  that  which  would  be  produced  by  "pouring  plaster 
of  Paris  into  the  pelvic  peritoneal  cavity. ' '  The  outer  wall  of  the 
exudation  is  composed  of  agglutinated  omentum,  intestines,  uterus, 
and  appendages.  The  abdominal  surface  of  the  mass  is  uneven, 
and  sometimes  shows  different  degrees  of  resistance  in  different 
parts.  As  in  pelvic  cellulitis,  so  also  in  pelvic  peritonitis,  the 
inflammation  may  end  in  resolution,  the  hard  exudation  melting 
away,  and  it,  together  with  the  contained  fluids,  being  absorbed. 
In  other  cases  suppuration  takes  place,  forming  one  or  more  ab- 
scesses. Such  abscess,  or  abscesses,  may  open  into  hollow  organs, 
or  externally,  as  in  the  case  of  the  abscesses  due  to  cellulitis.  After 
weeks  or  months  of  suffering  with  chills  and  fever,  recovery  may 
take  place.  Unfortunately,  however,  it  too  frequently  happens 
that  the  woman  becomes  a  chronic  invalid,  with  more  or  less  per- 
manent lesions  in  the  pelvis  and  lower  abdomen. 

Diffuse  Peritonitis  is  generally  associated  with  general  systemic 
infection,  although  the  symptoms  of  the  former  may  largely  pre- 
dominate. The  symptoms  of  diffuse  peritonitis  are  similar  to 
those  of  local  peritonitis,  but  appear  sooner  and  are  more  pro- 
nounced. The  chills  last  longer  and  are  more  severe.  The  pains 
are  extreme  and  extend  over  the  whole  abdomen.  These  pains 
may  cease  before  death,  or,  as  before  mentioned,  they  may  be  ab- 
sent altogether  in  very  bad  types  of  infection.  The  abdomen  is 
distended,  the  breathing  shallow,  rapid,  and  diaphragmatic.  The 
other  symptoms  are  those  which  have  been  described  in  connection 
with  general  infection,  and  will  again  be  referred  to  under  the 
heading  of  Acute  Sepsis. 

Acute  Sepsis. — In  giving  the  symptoms  of  acute  sepsis  I  shall 
closely  follow  Jellett.  The  symptoms  appear  from  twenty-four 
to  fifty  hours,  or  even  less,  after  infection.  Frequently  a  severe 
rigor  occurs  early,  during  which  the  temperature  rises  to  104°  or 
106°.  The  pulse  is  exceedingly  frequent,  and  is  even  out  of  pro- 
portion to  the  temperature.  Rigors  recur  frequently,  and  during 
the  intervals  the  patient  is  bathed  in  a  profuse  cold  perspiration. 
The  lochia  and  milk  secretion  are  either  not  established  or  cease 
completely.  The  patient  is  sleepless  and  looks  extremely  ill;  her 
face  is  pinched  and  often  jaundiced.  The  angles  of  the  mouth  and 
face  are  drawn  down  and  the  eyes  appear  sunken  into  the  head. 
Sometimes  in  the  worst  cases  the  patient  may  say  that  she  feels 


PUERPERAL    SEPTIC    IXFECTIOX  455 

extremely  wvU.  This  condition  is  calhMl  euphoria,  and  is  duo  to 
the  fact  that  the  higiicr  nerve  centers  are  dulled  by  the  poison 
which  is  circulating  in  the  system.  Frequently  there  is  a  diffuse 
septic  peritonitis.  The  duration  is  from  two  to  five  days,  or  some- 
times a  week. 

Pyaemia. — It  is  fi-('(|U(iitly  stated,  in  connection  with  pyaemia, 
that  the  symptoms  do  not  appear  until  the  seventh  to  the  twelfth 
day  after  delivery.  I  desire  to  repeat  that  I  consider  this  wrong. 
The  premonitory  symptoms  always  appear  within  two  or  three 
days  after  deli\'ery.  The  symptoms  are  really  very  much  like 
those  of  acute  sepsis,  but  the  serious  ones  come  on  later  and  last 
much  longer.  In  a  few  days  after  the  onset  of  the  serious  symp- 
toms metastatic  abscesses  form.  These  may  occur  in  any  part  of 
the  body,  but  they  generally  follow  one  of  two  definite  courses. 
They  are  found  in  one  class  of  cases  in  the  superficial  parts  of  the 
body,  generally  either  in  the  joints  or  subcutaneously ;  they  are 
found  in  the  other  class  in  the  deeper  organs,  as  the  liver,  lungs, 
spleen,  brain,  etc.  As  each  new  abscess  is  developed  there  is  a 
recurrence  of  the  rigors.  The  patient  may  gradually  recover,  but 
quite  as  frequently  dies.  Death  from  pyaemia  may  occur  in  several 
ways  :  from  exhaustion  due  to  long-continued  suppuration,  from 
septic  pneumonia,  peritonitis,  endocarditis,  or  from  abscesses  form- 
ing in  vital  organs,  such  as  the  liver  and  brain. 


TREATMENT   OF   PUERPERAL   INFECTION 

As  soon  as  symptoms  of  septicaemia  appear,  two  therapeutic 
procedures  should  be  at  once  considered  :  catharsis  and  local  treat- 
ment. Reference  is  here  made  especially  to  the  early  or  premoni- 
tory symptoms.  If,  on  the  second,  third,  or  fourth  day,  there 
are  headache,  sleeplessness,  rapid  pulse,  shght  elevation  of  tem- 
perature, and  chilly  feelings,  or  any  one  or  more  of  these,  the 
accoucheur  should  at  once  carry  out  the  first  mentioned  thera- 
peutic procedure. 

Catharsis. — Give  calomel,  one-half  to  one  grain  every  fifteen  to 
thirty  minutes,  for  four  to  six  doses  ;  follow  with,  magnesium  sul- 
phate, saturated  solution,  two  to  six  drams,  every  hour  or  two 
until  the  bowels  are  moved.  If  the  bowels  are  not  moved  after 
three  or  four  doses,  administer  an  enema  of  soap  suds,  a  pint  to  a 
quart,  with  a  tablespoonful  of  turpentine.     Aim  at  having  four  to 


456  LISTERISM    AND    OBSTETEICS 

six  watery  evacuations  in  the  twenty-four  hours  for  several  days  if 
necessary,  even  twelve  evacuations  in  the  twenty-four  hours  will 
do  no  harm.  Some  people  fear  the  danger  of  such  active  treatment. 
There  may  be  some  danger  of  causing  extreme  prostration,  and 
one  should,  of  course,  guard  against  that.  However,  the  danger 
in  that  respect  is  only  slight.  We  find,  from  cHnical  experience, 
that  the  elimination  of  any  poison  from  the  body  is  not  hkely  to 
produce  weakness ;  it  rather  tends  to  keep  up  the  strength  of  the 
resisting  forces  in  the  body.  If  the  symptoms  are  only  slight,  such 
as  headache,  insomnia,  and  are  relieved  by  the  calomel  and  sahne, 
stop  the  medication. 

We  may  carry  out  this  cathartic  treatment  with  confidence, 
because,  with  the  exception  of  certain  cases  of  acute  local  or  gen- 
eral peritonitis  (in  the  early  stages),  benefit  will  always  accrue. 
When  we  come  to  consider  further  the  advisability  of  local  treat- 
ment we  cannot  act  with  so  much  certainty.  If  the  symptoms 
are  due,  for  instance,  to  an  ordinary  influenza  or  a  slight  attack  of 
indigestion,  local  treatment  would  be  not  simply  useless  but  might 
do  actual  damage.  We  want  always  to  avoid  the  "  meddlesome" 
feature  in  our  work.  We  cannot  give  an  intra-uterine  douche,  or 
even  a  vaginal  douche,  without  causing  some  constitutional  effect, 
as  shown  by  increased  temperature  and  pulse  rate.  Therefore  we 
should  look  upon  such  procedures  as  evils,  to  be  avoided  unless 
we  adopt  them  to  remove  still  greater  evils  which  exist.  Mann 
advises  us  to  first  make  our  diagnosis  by  bacteriological  examina- 
tions according  to  the  methods  of  Doderlein  and  Whitridge  Will- 
iams. Mcllwraith  has  done  work  on  these  lines  in  our  General 
Hospital,  and  has  shown  that  such  examinations  aid  us  to  a  lim- 
ited extent  in  diagnosis,  prognosis,  and  treatment. 

Three  difficulties  in  this  connection  present  themselves.  First, 
a  great  many  have  not  the  facilities  for  carrying  out  such  investi- 
gations in  private  practice ;  second,  streptococci  and  staphylococci 
are  sometimes  found  in  the  puerperal  uterus  in  normal  cases; 
third,  a  certain  amount  of  very  valuable  time  may  be  lost  while 
waiting  for  the  results  of  such  investigations.  Virulent  strepto- 
cocci within  the  uterus  generally  travel  somewhat  rapidly  along 
the  lymphatics  toward  the  peri-uterine  tissues.  Under  such  cir- 
cumstances it  would  be  unfortunate  to  lose  twelve  to  twenty-four 
hours,  during  which  time  they  might  get  beyond  our  reach,  while, 
if  we  acted  promptly,  we  might  counteract  their  evil  effects. 


PUERPERAL    SEPTIC    INFECTION"  457 

The  following  simple  rules  may  be  accepted : 

1.  In  all  cases  when  the  lochia  become  offensive,  treat  locally. 

2.  When  it  is  suspected  that  portions  of  placenta  or  membranes 
are  retained  and  symptoms  of  sepsis  appear,  explore  the  interior 
of  the  uterus,  remove  debris  if  present,  and  wash  out. 

3.  When  in  doubt  as  to  the  condition  of  the  uterus  when  symp- 
toms of  sepsis  appear,  explore  and  wash  out.  If  return  flow  is 
clear  do  not  repeat. 

Local  Treatment. — I  fear  that,  in  a  large  proportion  of  cases, 
local  treatment  even  during  the  last  few  years  has  been  very 
imperfectly  or  improperly  carried  out.  Take,  for  instance,  the 
administration  of  intra-uterine  douches.  In  the  first  place,  a 
large  number  of  practitioners  do  not  know  how  to  administer  an 
intra-uterine  douche ;  in  the  second  place,  the  intra-uterine  douche, 
no  matter  how  well  it  may  be  administered,  frequently  if  not  gen- 
erally does  little  or  no  good.  In  saprsemia  it  only  washes  away 
some  shreds  and  clots,  while  it  leaves  putrid  debris  and  adherent 
clots  behind.  It  may  be,  however,  that  in  a  very  sm.all  proportion 
of  cases  it  cures  mild  saprsemia. 

Proper  Method  of  Local  Treatment  for  Uterine  Infection. — 
Let  an  assistant  administer  a  general  anaesthetic.  Adopt  all  the 
antiseptic  precautions  that  should  be  employed  for  an  abdominal 
section  or  any  other  surgical  operation.  After  having  made  your- 
self thoroughly  clean,  wash  the  vulva  and  vagina  as  before 
described,  then  introduce  the  hand  or  half  hand  into  the  vagina 
and  one  or  two  fingers  thence  into  the  uterus.  If  portions  of  the 
placenta  or  membranes  or  debris  of  any  sort  are  found,  scrape 
thoroughly  and  remove.  There  is  no  instrument  so  good  for  this 
purpose  as  the  intelligent  finger-tip. 

After  removing  the  debris,  wash  out  v/ith  hot  water  (110°-118° 
F.)  that  has  been  boiled,  or  with  a  weak  antiseptic  solution,  pack 
the  uterine  cavity  somewhat  tightly  with  iodoform  gauze  and  the 
vagina  loosely  with  the  same ;  leave  the  gauze  in  position  twenty 
to  thirty  hours. 

The  weak  antiseptic  solution  which  has  been  mentioned  is 
really  of  small  consequence.  The  sterilized  water  will  wash  out 
all  the  debris  which  has  been  loosened  with  the  fingers.  If  anti- 
septic solutions  which  are  strong  enough  to  kill  pathogenic  germs 
are  used,  they  will  produce  a  certain  amount  of  necrosed  tissue 
which  wiU  simply  form   a  culture   medium  for  the   growth  of 


458  LISTEEISM    AND    OBSTETEICS 

microbes,  while  if  they  are  not  strong  enough  to  kill  germs  they 
are  no  better  than  sterilized  water. 

Some  use  the  blunt  curette.  This  is  not  so  safe  nor  effective 
as  the  finger-tip.  Others  use  the  sharp  curette.  This  is  not  safe, 
because  it  is  likely  to  open  vessels  which  may  absorb  more  poison, 
or  it  may  destroy  that  so-called  reaction  zone  which  is  said  to  be 
formed  in  the  uterine  tissue  during  the  inflammatory  process, 
which  tends  to  resist  the  invasion  of  germs.  If  nothing  has  been 
found  in  the  uterus  and  the  discharges  are  not  offensive,  but  still 
the  patient  becomes  worse,  the  system  is  profoundly  infected,  and 
any  further  local  treatment  of  the  uterine  cavity  will  do  more 
harm  than  good. 

Local  treatment  is  especially  useful  in  ordinary  saprsemia, 
which  it  generally  cures  at  once.  It  also  produces  very  satisfactory 
results  in  a  certain  proportion  of  cases  of  mild  infection. 

Other  forms  of  local  treatment  are  suitable  for  pelvic  cellulitis 
and  pelvic  peritonitis,  especially  after  the  exudations  can  be 
detected.  Vaginal  douching,  according  to  the  directions  given  by 
Emmet  about  twenty-five  years  ago,  is  generally  soothing  and 
promotes  the  absorption  of  the  inflammatory  product.  It  fell 
into  disrepute  a  few  years  ago,  but  now  seems  to  be  returning 
again  to  popularity.  Douching  to  be  effective  should  be  admin- 
istered in  a  thorough  and  careful  manner  by  the  physician  or  a 
skilled  nurse.  The  patient  should  not  be  made  uncomfortable, 
the  pelvis  should  be  on  a  higher  level  than  the  shoulders,  a  good 
douche  pan  should  be  used,  the  temperature  of  the  water  should 
be  115°-118°  F.  One  or  two  gallons  of  water  should  be  used 
for  a  douche,  which  should  be  given  twice  a  day,  if  it  does 
not  cause  fatigue.  As  to  that,  much  will  depend  on  the  skill  of 
the  nurse. 

It  is  well  in  most  cases  to  paint  the  groin  occasionally  with 
tincture  of  iodine.  Garrigues  does  this  once  a  day,  and  then  cov- 
ers it  with  a  piece  of  lint  soaked  in  this  lotion, 

I^    Acidi    carboHci 3  j    (4   gm.), 

T"\    ^ liijOOgm.), 

with  the  expectation  that  it  will  prevent  the  skin  from  cracking, 
and  allow  one  to  continue  the  use  of  the  iodine  and  favor  its  absorp- 


PUEEPEEAL    SEPTIC    INFECTION  459 

tion.  When  the  tenderness  has  subsided  sufficiently  to  allow  a 
speculum  to  be  introduced,  he  also  paints  the  vault  of  the  vagina 
every  three  days.  One  should  be  careful  not  to  use  too  much 
tincture  of  iodine,  and  it  should  l)e  applied  with  a  very  small 
pledget.  I  prefer  to  use,  instead  of  the  tincture,  equal  parts 
of  the  compound  solution  of  iodine  and  glycerine  every  day  or 
two,  taking  care  not  to  use  too  much.  Reference  will  be  made 
to  the  treatment  of  abscesses  in  connection  with  operative  treat- 
ment. 

Operative  Treatment. — When  the  streptococci  have  passed 
beyond  the  reach  of  the  curette,  Henrotin  advises  certain  operative 
procedures  with  a  view  of  stopping  the  ravages  of  the  organisms 
before  the  entire  system  is  poisoned.  When  the  germs  pass 
through  the  uterine  walls  they  set  up  a  peritonitis,  or  parametritis, 
or  both.  A  fibrinous  and  serous  exudate  is  thrown  out  which 
accumulates  in  the  pelvis  or  in  the  general  peritoneal  cavity. 
Henrotin  opens  the  posterior  fornix  of  the  vagina  and  passes  the 
finger  through  this  opening  into  the  peritoneal  cavity,  with  a  view 
of  draining  away  as  much  of  this  fluid  as  possible.  After  a  thor- 
ough exploration  with  the  finger  he  packs  the  cul-de-sac  with 
iodoform  gauze.  Pry  or  approves  of  this  plan.  He  thinks  it  is 
especially  useful  when  there  is  a  mixed  infection,  as,  for  instance, 
saprophytes  and  streptococci  together.  Mann  also  goes  somewhat 
farther  with  this  operation,  and  opens  recent  accumulations  of 
pus  within  the  tubes  or  broad  ligaments.  He  tells  us  the  opening 
of  the  cid-cle-sac  is  a  very  simple  operation,  attended  with  little 
or  no  risk,  and  when  nothing  is  found  the  wound  heals  in  a  very 
short  time.  Our  results  from  this  operation  in  Toronto  have  been 
somewhat  disappointing. 

In  a  certain  proportion  of  cases  we  have  a  pelvic  abscess.  The 
proper  treatment  for  such  an  abscess  is  to  open  it  and  give  free 
vent  to  the  pus.  If  the  abscess  is  not  interfered  with  it  generally 
opens  in  time  through  the  wall  of  the  bowel.  It  may,  however, 
open  into  the  bladder,  uterus,  vagina,  or  externally,  above  or 
below  Poupart's  ligament.  After  discharging  for  a  time  the  hard 
wall  surrounding  the  abscess  may  become  absorbed  and  a  com- 
plete cure  may  be  the  result. 

The  following  rules  as  to  active  interference  will,  I  think, 
fairly  represent  the  views  of  the  majority  of  conservati"\'e  obstet- 
ricians : 


460  LISTEEISM    AND    OBSTETRICS 

Active  curettage,  especially  with  a  sharp  curette,  or  even  with 
a  large  dull  wire  curette,  is  dangerous. 

Garrigues's  opinion  in  this  regard  is  worth  much.  He  says  he 
does  not  remember  to  have  seen  a  patient  recover  when  the  curette 
was  used  after  sepsis  had  set  in  after  childbirth. 

Henrotin's  operative  methods  are  not  always  followed  by 
satisfactory  results. 

A  pelvic  abscess,  whether  cellular  or  peritoneal,  should  always 
be  opened  and  freely  drained. 

Puerperal  Ulcers. — Ulcers  are  frequently  found  and  vary  to  a 
considerable  extent  in  size.  They  generally  have  a  gray,  slough- 
ing base,  with  an  inflamed  margin,  situated  on  lacerations  of  the 
genital  tract.  Local  treatment  is  all  that  is  necessary  for  such 
ulcers.  Do  not  use  a  vaginal  douche,  for  fear  of  carrying  some 
of  the  discharge  from  an  ulcer  into  the  uterus.  It  is  well  to  have 
the  head  of  the  bed  raised  in  order  to  favor  free  drainage.  Intro- 
duce a  speculum,  get  a  good  view  of  the  ulcer,  and  apply  pure 
carbolic  acid  and  then  iodoform  powder ;  or  nitrate  of  silver,  40 
grains  to  the  ounce. 

Medicinal  Treatment  in  Addition  to  the  Administration  of 
Cathartics. — Probably  the  best  drug  at  our  disposal  is  alcohol. 
The  patient  should  take  as  much  as  possible.  Jellett  says  that 
she  should  have  as  much  as  she  can  be  urged  to  take  without  any 
qualification,  and  he  considers  that  the  amount  should  be  about 
from  16  to  24  ounces  in  twenty-four  hours.  Reynolds  recommends 
us  to  give  whisky  in  sufficient  quantities  to  preserve  a  normal 
fulness  of  the  pulse  without  producing  any  loquacity  or  dizziness 
— that  is,  we  should  stimulate  as  much  as  possible  without  pro- 
ducing intoxication.  Jewett  recommends  the  administration  of 
a  quart  of  brandy  or  its  equivalent  daily,  and  recommends  that 
whisky,  brandy,  and  the  wines  be  used  in  alternation. 

Certain  tonics  are  useful,  and  are  said  to  hinder  waste  and  to 
promote  oxidation  of  the  toxines  and  the  products  of  tissue  dis- 
integration. The  best  of  these  is  probably  strychnine,  gV  of  a 
grain  every  three  to  six  hours.  Quinine,  1  grain  with  10  minims 
of  hydrochloric  acid  every  four  to  eight  hours,  appears  to  answer  in 
some  cases  better  than  strychnine.  It  was  the  custom,  especially 
a  few  years  ago,  to  give  quinine  in  large  doses  to  reduce  the  tem- 
perature. I  seldom  use  quinine  for  this  purpose,  never  unless 
the  temperature  is  over  104°.     Jewett  says  that  large  doses  are 


PUEEPERAL    SEPTIC    INFECTION"  461 

injurious  by  hindering  oxidation.  Tincture  of  digitalis  or  tinc- 
ture of  strophanthus  in  10  to  15  minim  doses,  given  every  four  to 
eight  hours,  are  useful  for  weak  heart.  Some,  however,  prefer 
to  use  sparteine  or  caffeine  for  heart  depression.  Coal-tar  anti- 
pyretics, such  as  antipyrine,  antifebrine,  have  been  used  to  bring 
down  the  temperature,  but  they  are  dangerous  from  the  fact  that 
they  act  as  depressants.  Robbin  tells  us  that  they  also  hinder 
elimination  of  microbic  poisons  and  the  products  of  tissue  dis- 
integration by  preventing  their  oxidation. 

Feeding. — The  most  important  matter  in  connection  with  feed- 
ing is  probably  the  administration  of  fluids  in  as  large  quantity 
as  possible,  and  especially  water,  either  plain  or  mild  alkaline 
mineral  waters.  It  has  been  found  by  experiments  on  animals 
that  the  quantity  of  septic  poison  required  to  intoxicate  is  doubled 
or  trebled  when  the  animal  drinks  abundantl}-  of  mildly  alkaline 
waters.  Alkalies  are  believed  to  facilitate  the  combustion  of  or- 
ganic substances  in  the  blood.  Diuretic  drugs  are  used  by  many, 
acting  on  the  view  that  it  is  well  to  endeavor  to  eliminate  the 
poison  by  all  the  emunctories,  but  especially  the  skin,  kidneys,  and 
bowels.     Plain  water  is  the  best  diuretic. 

Give  opium  and  morphine  in  full  doses  for  severe  pain,  but  it 
is  advisable  to  have  the  bowels  freely  moved  before  and  during 
the  administration  of  opiates.  Some  take  a  rather  extreme  view 
of  the  effects  of  opium  and  say  that  opiates  should  not  be  used 
at  all.  During  the  last  few  years  there  has  been  a  reaction  against 
this  view.  Garrigues  uses  opium  or  morphine  in  very  large  doses 
for  puerperal  peritonitis.  He  endeavors  to  give  prompt  relief  by 
injecting  hypodermically  at  the  beginning  ^  of  a  grain  of  morphine, 
and  giving  thereafter  by  the  mouth  |-  or  ^  grain  every  half  hour 
until  the  patient  is  fully  under  the  influence  of  the  drug — i.e.,  free 
from  pain,  but  not  too  deeply  narcotized  to  prevent  her  from  being 
aroused.  When  the  heart  is  weak  a  little  atropine  may  be  com- 
bined with  the  morphine. 

If  the  patient  has  general  peritonitis  with  severe  pain  when 
first  seen  it  is  probably  better  to  follow  Garrigues 's  advice.  First 
narcotize  sufficiently  to  relieve  pain ;  then  give  enemata :  glycer- 
ine (  3  ij-  3  iv),  or  a  quart  of  flaxseed-meal  tea  containing  one  or 
two  tablespoonfuls  of  castor  oil  and  a  dessertspoonful  of  glycer- 
ine. A  teaspoonful  of  inspissated  ox-gall  ( fel  hovis)  may  be  added. 
For  vomiting  give  cocaine  hypodermically,  gr.  ^  (8  gm.)  every 


462  LISTEEISM    AND    OBSTETRICS 

two  to  four  hours,  or  hydrocyanic  acid  by  the  mouth  according 
to  this  formula  (Garrigues) : 

IJ    Acidi  hydrocyanic  diluti 3  ss.  (2  gm.) ; 

Acidi  citrici  j    --  ,••  /o 

3  ij  (8  gm.. 


Sodii  bicarbonatis 

Syrupi  rubi  idsei 3  ss.  (15  gm.) ; 

Aquae  destillatse  ad 3  vj  (180  gm.). 

M.     Sig. :  A  tablespoonful  every  one,  two,  or  three  hours. 

Unguentum  Crede  has  been  used  for  some  years  on  the  Con- 
tinent and  in  some  parts  of  the  United  States.  It  contains  silver 
in  a  soluble  form  called  collargolum,  which,  after  absorption,  enters 
the  lymphatics  and  circulates  in  the  blood.  The  collargol  may 
also  be  injected  under  the  skin  or  into  a  vein,  or  it  may  be  taken  by 
the  mouth,  or  be  placed  in  certain  cavities,  such  as  the  uterine  and 
peritoneal  cavities.  In  inunction  (the  method  generally  employed) 
thirty  to  forty  grains  (2-3  gm.)  of  the  ointment  are  rubbed  once  a 
day  into  the  skin,  where  it  is  soft  and  free  from  hair,  as,  for  in- 
stance, the  inner  sides  of  the  arms  or  thighs.  This  procedure  is 
said  by  some  to  yield  good  results  in  general  systemic  infections. 

Mannorek's  Antistreptococcic  Serum.  —  Among  the  various 
antitoxic  sertims  which  have  been  used  during  the  last  ten  years, 
none  created  more  interest  for  a  time  than  the  antistreptococcic 
serum.  Much  was  expected  of  it,  but  the  results  in  the  majority  of 
cases  were  quite  disappointing.  A  committee  appointed  by  the 
American  Gynaecological  Society  condemned  it  in  a  report  which 
was  presented  in  May,  1899.  Their  investigations  indicated,  how- 
ever, that  the  serum  was  practically  harmless,  but  many  observers 
have  concluded  that  it  is  quite  injurious.  It  should  be  remem- 
bered that  in  many  cases  the  serum  was  only  used  after  curette- 
ment — an  operation  with  a  very  bad  record. 

In  August,  1899,  the  subject  was  fully  discussed  at  the  meeting 
of  the  British  Medical  Association.  Herbert  Spencer's  conclusions 
(generally  endorsed)  were : 

1.  Serum  therapy,  as  usually  applied,  has  not  a  scientific  basis. 

2.  It  has  not  lowered  the  mortality  of  puerperal  sepsis. 

3.  It  usually  lowers  the  temperature  and  sometimes  improves 
the  general  condition. 

4.  Its  use  is  not  free  from  danger. 


PUERPERAL    SEPTIC    INFECTION  463 

It  is  iinfortunato  that  tlio  sul)jcct  of  .soruin  therapeutics  re- 
mains so  long  indefinite.  This  is  partly  due  to  the  fact  that  the 
standards  of  strength  of  most  of  the  antitoxic  serums  are,  to  a  cer- 
tain extent,  uncertain.  Probably  the  only  exceptions  at  present 
arc  the  antidiphtheritic  and  the  antitetanic  serums.  The  doses 
and  the  effects  of  dosage  in  the  case  of  these  two  serums  are  fairly 
definite,  and  the  results  in  the  treatment  of  diphtheria  and  tetanus, 
in  the  opinion  of  the  great  majority  of  clinicians,  have  been  emi- 
nently satisfactory.  Let  us  hope  that  in  the  near  future  we  may 
get  equally  satisfactory  results  from  the  use  of  antistreptococcic 
serum  in  suitable  cases.  After  having  passed  through  various 
phases  of  hope,  doubt,  and  actual  unbelief,  I  now  hold  opinions 
which  are  not  in  accordance  with  the  report  of  the  Committee 
of  the  American  Gynaecological  Society.  These  may  be  briefly 
expressed  as  follows : 

1.  The  injection  of  Marmorek's  serum  does  occasionally  cure 
antistreptococcic  infection. 

2.  The  serum  is  not  always  harmless ;  it  is  frequently  injurious. 
Unfortunately,  those  who  believe  in  the  occasional  efficacy  of 

the  remedy  cannot  give  any  definite  rules  for  guidance. 

During  my  own  attack  of  septicaemia  in  the  fall  of  1900,  Drs. 
Caven  and  Bruce  determined  to  try  the  serum.  It  was  injected  at 
a  time  when  I  was  suffering  from  intense  pain,  which  was  but  little 
influenced  by  morphine.  The  pain  appeared  to  be  deeply  seated 
in  or  near  the  left  hip  joint.  After  the  injection  I  gradually  got 
a  sensation  as  if  something  were  warming  the  stagnant  congealed 
blood  within  my  heart.  This  warm  blood  soon  commenced  to 
flow  in  all  directions,  and  as  it  did  so  my  pain  scattered  and  finally 
disappeared,  causing  a  dehcious  feeling  of  rest  and  peace,  followed 
shortly  by  an  inchnation  to  take  some  interest  in  my  surroundings 
and  a  desire  to  live.  How  much  hysteria  there  was  in  me  at  the 
time  I  know  not,  but  it  appeared  to  me  that  the  serum  brought  me 
back  to  life.  I  know  very  little  as  to  particulars,  as  I  have  never 
consulted  the  history  or  the  charts ;  but  I  understand  that  my 
medical  attendants.  Osier,  Caven  and  Bruce,  thought  that  it 
accomplished  much  good. 

McUwraith  has  pubHshed  some  histories  of  cases  coming  under 
our  observation.  In  one  instance  I  watched  the  patient  very  care- 
fully and  thought  that  she  showed  marked  improvement  after  each 
injection  (as  shown  by  effect  on  .temperature,  pulse,  and  in  other 
81 


464  LISTEEISM    AND    OBSTETEICS 

ways),  and  finally  made  a  good  recovery.  I  have  seen  some 
patients  on  whom  the  serum  treatment  appeared  to  have  a 
bad  effect ;  other  patients  on  whom  it  appeared  to  have  no  effect 
whatever. 

I  should  recommend  the  following  rules : 

Use  the  serum  in  cases  of  acute  septic  infection  where  the 
patient  is  steadily  growing  worse  under  ordinary  treatment — i.e., 
practically  as  a  last  resort. 

Do  not  use  it  in  cases  of  mild  septicaemia,  chronic  septicaemia, 
pyaemia,  or  in  localized  infections. 

Directions  as  to  Injections. — Make  the  initial  dose  20  c.c,  never 
less.  Watch  the  effect  of  this,  and  if  patient  shows  any  signs  of 
improvement,  inject  10  c.c.  every  twelve  to  twenty-four  hours  for 
three  or  four  days.  In  the  Toronto  General  Hospital  we  have 
generally  injected  between  the  shoulder-blades. 

Nuclein,  a  substance  obtained  from  yeast,  has  been  used  to 
produce  an  artificial  leucocytosis  with  a  hope  that  the  leucocytes, 
with  large  reinforcements,  may  be  able  to  destroy  the  pathogenic 
microbes.  Hofbauer  reported  favorable  results  from  its  admin- 
istration in  1896.  Hirst  has  used  it  for  some  years  and  speaks 
favorably  of  it.  The  nuclein  solution  is  given  hypodermically,  or 
by  the  mouth,  according  to  directions  issued  by  the  manufacturer. 
The  initial  dose  is  usually  10  minims  (60  centigrammes)  hypo- 
dermically twice  a  day,  or  3  ss.  (2  gm.)  by  the  mouth.  The  dose 
is  generally  increased  slightly  from  day  to  day. 

Enemata  and  Subcutaneous  Injections  of  Normal  Saline  Solu- 
tions, as  recommended  for  toxaemia  and  eclampsia,  should  always 
be  given.  Intravenous  injections  are  used  by  some;  but  they  are 
probably  no  more  efficacious  than  the  subcutaneous  injections, 
require  great  care  and  considerable  skill  in  technique,  and  are 
more  or  less  dangerous.    • 

Atmokausis — i.  e.,  the  intra-uterine  use  of  steam — has  been 
employed,  but  has  been  followed  in  many  cases  by  results  so  dis- 
astrous that  it  is  worthy  of  no  favorable  consideration. 

Hysterectomy. — This  operation  has  been  performed  by  a  few 
with  the  aim  of  removing  the  infected  uterus  before  the  microbes 
have  invaded  the  general  system;  but  it  is  hard  to  conceive  of  a 
case  where  the  uterus  is  so  affected  as  to  require  removal  without 
general  infection. 

The  following  brief  notes  of  some  cases  in  practice  will  iUus- 


PUERPEEAL    SEPTIC    INFECTION  465 

trate  certain  points  as  to  the  nature  and  treatment  of  puerperal 
infections. 

Mrs.  A.,  aged  thirty.  Labor  normal.  Felt  ill  on  second  day,  grew 
worse  until  I  saw  her  on  the  fifth  day  after  delivery.  Pulse  125,  temper- 
ature 104°.  Lochia  offensive,  with  ordinary  symptoms  of  sepsis.  Chloro- 
form administered ;  vulva  and  vagina  washed ;  hand  introduced  into  the 
vagina,  two  fingers  into  the  uterus;  scraped  the  interior  of  the  uterus, 
bringing  away  considerable  debris.  Intra-uterine  injection  of  hot  water; 
uterine  cavity  packed  with  iodoform  gauze;  also  vagina  packed  loosely, 
gauze  left  in  twenty-four  hours.  When  the  gauze  was  removed  patient's 
temperature  was  99°,  pulse  100.  Patient  was  then  practically  well;  there 
were  no  other  serious  symptoms. 

This  was  probably  an  ordinary  case  of  uncomplicated  saprsemia. 
I  have  frequently  asked  members  of  my  classes  the  following  cjues- 
tion :  If  you  see  a  patient  on  the  fifth  day  after  delivery  and 
find  high  temperature,  rapid  pulse,  headache,  sleeplessness,  etc., 
with  offensive  lochial  discharge;  if  you  see  another  patient  Avith 
similar  symptoms  but  no  offensive  lochial  discharge,  which  of  the 
patients  is  probably  in  the  worse  condition?  The  answer  has 
frequently  been,  the  patient  having  offensive  lochial  discharge. 
Such  answer  is  generally,  at  least,  wrong,  because  in  many  very 
serious  cases  of  streptococcic  infection  the  lochia  are  not  at  all 
offensive  at  any  time.  When  there  are  bad  symptoms  with  no 
change  in  the  lochia  there  are  probably  serious  constitutional 
conditions  with  general  systemic  infection.  But  when  the  lochia 
are  offensive  there  is  reason  to  suspect  that  the  condition  is  due 
to  the  decomposition  in  consequence  of  the  presence  of  saprophytic 
bacteria.  Nothing  can  be  more  satisfactory  than  the  results  of 
treatment  in  simple  saprsemia. 

Mrs.  D.,  aged  thirty-five.  Ill  para.  Labor  normal.  Suffered  from 
headache,  sleeplessness,  and  chilly  feelings  during  the  second  week. 
Pulse  slightly  rapid,  temperature  occasionally  increased  a  little.  Symp- 
toms supposed  to  be  due  to  nerve  disturbances.  I  first  saw  the  patient 
on  the  fifteenth  day  after  deUvery.  Temperature  103°,  pulse  120,  every 
eA^idence  of  serious  illness.  Pain  and  tenderness  in  left  iliac  region.  In- 
ternal examination  showed  swelling  and  tenderness  on  the  left  side  of 
the  uterus.  In  a  few  days — that  is,  in  about  three  or  four  weeks  after 
labor — a  well-defined  mass  could  be  felt  between  the  left  of  the  cervix 
uteri  and  the  left  iliac  fossa.  This  mass  remained  without  much  change 
for  some  weeks,  when  there  was  a  free  discharge  of  pus  from  the  rectiun. 
Tliis  discharge  continued,  more  or  less,  for  four  weeks.     After  the  dis- 


466  LISTEEISM    AND    OBSTETRICS 

charge  ceased  the  hard  wall  of  the  abscess  appeared  to  melt  away  slowly 
and  patient  made  a  fair  recovery.  Eight  months  after  labor  the  uterus 
was  apparently  normal  in  size,  and  freely  movable.  There  was  no  local 
manifestation  of  any  pelvic  lesions. 

An  important  question  might  come  up  in  connection  with  this 
case.  Would  it  not  have  been  better  to  open  the  abscess  in  such 
a  way  as  to  have  free  drainage?  The  proper  answer  is,  Yes.  In 
a  large  proportion  of  cases  of  pelvic  abscess  it  is  a  very  simple 
matter  to  make  an  opening  and  evacuate  the  pus.  The  abscess 
has  been  formed  in  the  cellular  tissues,  generally,  if  not  always, 
between  the  layers  of  the  broad  ligament,  and  has  separated  these 
layers  and  pushed  the  peritonaeum  upward  as  it  increased  in  size. 
Under  such  circumstances,  after  it  has  reached  a  point  some  inches 
above  the  pubes,  the  abscess  may  be  opened  without  exposing  the 
peritoneal  cavity.  In  this  case  the  patient  and  her  friends  abso- 
lutely refused  to  allow  any  operative  interference. 

Mrs.  S.,  aged  thirty.  Had  two  children  and  three  abortions.  Septem- 
ber 22d  advanced  three  months  in  pregnancy,  abortion.  Attended  by 
Dr.  K.  September  24th  and  25th,  temperature  100-101°,  pulse  110.  Sep- 
tember 26th,  temperature  102°,  pulse  120.  Chloroform  administered  by 
Dr.  L.  Dr.  K.  introduced  hand  into  vagina  and  finger  into  the  uterus; 
removed  uterine  contents  and  packed  with  iodoform  gauze.  September 
27th,  patient  better  in  the  morning.  At  one  o'clock  seemed  not  quite  so 
well,  temperature  101°,  pulse  110.  Dr.  K.  removed  gauze,  washed  out 
the  uterus,  and  curetted.  Little  or  nothing  found  in  the  uterus.  At 
4  P.M.,  temperature  104°,  pulse  120.  At  11  p.m.  I  saw  the  patient  in 
consultation  with  Dr.  K.  Temperature  102.5°,  pulse  140.  On  vaginal 
examination  found  os  contracted,  could  not  introduce  finger.  Uterus 
not  tender.  After  I  was  in  the  room  twenty  minutes,  pulse  120.  I  ad- 
vised no  further  interference.  September  28th,  patient  much  better, 
temperature  100°,  pulse  100.  September  30th,  patient  completely  re- 
covered.    Temperature  and  pulse  normal. 

When  I  was  called  in  to  see  the  patient  on  the  night  of  Septem- 
ber 27th  I  was  considerably  puzzled.  It  will  be  noticed  that  at 
four  o'clock  in  the  afternoon  temperature  was  104°  and  pulse  120. 
When  I  saw  her  at  eleven  o'clock  the  temperature  was  102.5°, 
pulse  140.  I  thought  it  a  favorable  sign  to  find  the  temperature 
reduced,  and  I  thought  at  the  same  time  that  the  rapidity  of  the 
pulse  (140)  might  be  due  to  nervous  causes  produced  by  my 
entrance  into  the  room.     I  was  pleased  but  not  greatly  surprised 


PUERPEKAL    SEPTIC    INFECTION  467 

to  find  in  twenty  minutes  that  the  pulse  was  only  120.  I  consid- 
ered carefully  what  Dr.  K.,  a  very  competent  and  careful  prac- 
titioner, had  done.  He  had,  in  my  opinion,  done  exactly  the 
right  thing  in  having  his  patient  anaesthetized,  and  thoroughly 
exploring  antl  clearing  out  the  uterine  cavity  and  packing  with 
iodoform  gauze.  I  do  not  know  why  the  temperature  and  pulse 
were  aljnormal  the  next  day  at  one  o'clock,  but  I  think  I  can  tell 
the  cause  of  the  condition  at  fcnu*  o'clock,  with  temperature  104°, 
pulse  120.  This  was  almost  certainly  due  to  the  intra-uterine 
douche  and  curettement.  As  before  stated,  the  intra-uterine 
douche  always  produces  some,  and  sometimes  very  considerable, 
constitutional  disturbance.  I  also  feel  certain  that  curettement 
in  this  case  was  worse  than  useless.  This  case  has  been  described 
somewhat  in  detail  to  illustrate  the  fact  that  an  honest  and  con- 
scientious physician  may  do  too  much  rather  than  too  httle. 

In  this  connection  I  wish  to  give  a  report  of  another  case  with 
a  very  sad  ending: 

Mrs.  C,  aged  twenty-eight.  Two  children.  Four  months  advanced 
in  pregnancy.  Abortion.  First  attended  by  Dr.  X.  Two  days  after 
came  under  the  care  of  Dr.  Y.  Nothing  known  about  Dr.  X.'s  treatment. 
Dr.  Y.  gave  intra-uterine  douches  every  four  hours  for  about  a  day  and  a 
half.  I  was  called  in  on  the  morning  of  the  fifth  day.  Temperature  99°, 
pulse  150,  extremities  cold.  Patient  felt  comfortable,  faculties  clear,  but 
she  was  evidently  dying.  Dr.  Y.  washed  out  the  uterus  again  in  my 
presence,  the  return  flow  being  perfectly  clear.  We  were  simply  douching 
a  dying  woman  without  any  possibility  of  doing  any  good,  because  the 
poison  was  not  situated  in  the  uterine  mucosa,  but  had  traveled  far  be- 
yond that  into  every  part  of  the  system.  In  this  instance  I  had  no  idea 
that  the  douching  did  any  particular  harm,  but  I  am  certain  it  was  doing 
no  good,  and  I  am  greatly  opposed,  as  I  have  before  intimated,  to  the  use 
of  intra-uterine  douche  when  I  am  sure  that  it  is  at  least  unnecessary. 
The  patient  died  in  about  half  an  hour  after  the  last  douche — that  is, 
probably  about  four  days  after  infection.  This  is  a  typical  example  of 
death  from  very  acute  sepsis  with  the  condition  called  euphoria. 

The  following  is  a  typical  example  of  that  condition  produced 
by  septic  infection  which  has  long  been  known  to  clinicians  as 
pyaemia : 

M.  M.,  aged  seventeen.  Single.  A  strong,  healthy  girl,  delivered  of 
a  well-developed  male  child  March  28,  1893,  at  the  Burnside.  Three 
stitches  introduced  in  a  torn  perinseum,  sterilized  silkworm-gut  being 
used.     On  the  evening  of  March  30th  (60  hours  after  delivery)  pulse  92. 


468  LISTERISM    AND    OBSTETRICS 

Next  morning  pulse  95,  temperature  100.6°.  Magnesium  sulphate  ad- 
ministered until  bowels  moved  freely.  Condition  improved  for  three  or 
four  days.  Stitches  removed  seven  days  after  labor.  A  little  pus  found 
in  one  stitch  hole.  No  union.  Patient  complained  of  pain  in  her  right 
leg  and  arm  April  6th  (nine  days  after  labor),  arm  swollen.  April  9th 
(twelve  days  after  labor)  patient  was  anaemic,  breathing  very  rapidly, 
right  forearm  red  and  swollen  on  dorsal  aspect,  the  affected  part  being 
exquisitely  tender.  Left  arm  also  swollen  and  tender.  Calf  of  right  leg 
slightly  swoUen  and  very  tender.  No  pain  or  distention  of  abdomen, 
no  headache;  took  nourishment  well  ;  pulse  120,  temperature  102.2°, 
respiration  40.  Free  incisions  were  made  in  right  forearm  and  left  arm, 
the  knife  being  carried  to  the  bone.  The  subcutaneous  tissues  of  the 
right  forearm  presented  a  very  peculiar  appearance,  gray  in  color,  looking 
something  like  clear  transparent  jelly,  no  pus  nor  fluid  of  any  kind. 
Only  the  subcutaneous  tissues  affected.  Discharge  from  wounds  became 
purulent  three  days  after  incision,  contained  streptococci  in  abundance. 
In  addition  to  these  local  measures  patient  was  treated  by  free  stimulation, 
taking  about  twelve  ounces  of  whisky  in  twenty-four  hours.  For  a 
time  quinine  was  administered,  but  without  effect.  Salol  was  substituted, 
but  it  disturbed  her  digestion  and  was  discontinued.  The  patient's 
condition  gradually  became  worse,  persistent  high  temperature  101°  to 
105.6°,  remarkably  rapid  respirations,  ranging  during  the  last  week  from 
36  to  74  per  minute,  more  rapid  during  sleep.  Patient  restless,  very  ner- 
vous. Lips  quivered  but  never  had  an  actual  rigor.  Amount  of  pus 
discharged  from  wounds  never  very  great.  Died  April  21st,  twenty-four 
days  after  confinement. 

Post  mortem  by  Professor  Caven.  No  abscesses  in  internal  organs. 
Peritonaeum  normal  in  appearance,  uterus  enlarged  and  soft,  vagina  nor- 
mal. Careful  dissection  of  the  vagina  and  broad  ligament,  after  removal, 
showed  the  veins  running  from  the  neighborhood  of  the  perineal  lacera- 
tions to  be  partly  filled  with  puriform  clot  and  to  present  the  appearance 
of  acute  phlebitis. 

Microscopic  examination  demonstrated  the  presence  of  streptococci 
in  great  numbers  in  the  clot.  Posterior  a,spects  of  both  forearms  and  of 
the  left  arm  presented  an  extensive  subcutaneous  suppuration  spreading 
widely  beneath  the  skin,  but  to  a  very  slight  degree  along  the  intermus- 
cular septa.  On  the  left  side  there  was  also  subcutaneous  suppuration 
over  the  back  of  the  hand,  extending  to  the  roots  of  the  fingers.  The  calf 
of  the  right  leg,  on  incision,  was  found  in  the  same  condition  as  the  arms, 
the  suppuration  being  extensive  but  strictly  limited  to  the  subcutaneous 
tissues;  about  twelve  ounces  of  pus  found  here.  Phlebitis  was  found 
extending  up  into  the  thigh. 

Dr.  Primrose  assisted  me  in  taking  care  of  this  patient,  making 
the  incisions  and  looking  after  the  dressings.     There  were  many 


PUEEPERAL    SEPTIC    INFECTION 


469 


interesting  points  connocterl  with  the  same,  some  of  which  I  could 
never  clearly  understand.  While  I  call  it  a  case  of  pyaemia,  I 
consider  it  a  form  of  septicaemia  which  frequently  ends  in  recov- 
ery. The  nerve  centers  were  not  suddenly  overpowered  by  the 
intensity  and  virulence  of  the  poison,  as  is  the  case  in  the  most 
malignant  form,  which  kills  so  rapidly  and  leaves  little  in  the  way 
of  gross  lesions  to  be  found  post  mortem,  and  yet  the  blood-vessels 
appear  to  have  been  the  principal  carriers  of  the  poison;  conse- 


FiG.  162. — Letjccpcenia. 

144  squares  Thoma  Zeiss  diluted  1-10  0.3  per  cent,  acetic  acid,  methyl  green. 
P,  polymorphnuclear;  LM,  large  mononuclear;  SM,  small  mononuclear 
(W.  N.  Meldrum). 


quently  I  should  suppose  there  was  no  let  or  hindrance  to  a  rapid 
infection  of  the  whole  system.  The  serous  and  mucous  mem- 
branes were  remarkably  free  from  any  signs  of  serious  infection. 
It  belongs  to  that  class  of  cases  in  which  the  superficial  parts  of 
the  body  are  especially  affected.  While  the  force  of  the  poison 
appears  to  have  been  expended  in  the  subcutaneous  tissues,  there 
must  have  been  a  serious  infection  of  certain  nerve  centers  which 
produced  the  extreme  rapidity  of  respiration  which  was  out  of 
proportion  to  the  accompanying  symptoms.     Why  this  rapidity 


470 


LISTEEISM    AND    OBSTETEICS 


of  respiration  was  most  marked,  as  a  general  rule,  during  sleep, 
I  do  not  know. 

It  will  be  noticed  in  the  synopsis  of  Dr.  Caven's  post-mortem 
report  that  there  was  a  collection  of  pus  strictly  limited  to  the  sub- 
cutaneous tissues  in  the  calf  of  the  right  leg.  It  caused  me  great 
surprise  to  find  that  there  were  twelve  ounces  of  pus  in  this  region. 
We  made  incisions  in  other  parts.  Why  did  we  make  none  here? 
We  at  one  time  suspected  the  presence  of  pus  and  intended  to 
incise.  Another  careful  examination  shortly  after  gave  us  the  im- 
pression that  our  previous  opinion  was  wrong  and  consequently 
no  incision  was  made.  The  lesson  to  be  learned  is  that  in  all  such 
Cases  the  rule  should  be,  when  in  doubt  as  to  the  presence  of  pus, 
to  incise  without  waiting  for  positive  evidence. 

Another  case  of  pysemia.  Mrs.  D.,  IV  para,  admitted  to  Gen- 
eral Hospital  ten  days  after  labor.  Symptoms  of  septic  infection. 
After  a  couple  of  weeks  some  doubt  as  to  diagnosis.     Typhoid  fever 


Fig.  163. — Normal  Blood. 

P,  polymorphnuclear    LM,  large  mononuclear;  SM,  small  mononuclear 

(W.  N.  Meldrum). 

suspected.  Blood  examination  by  Dr.  McLaurin.  Widal  test,  nega- 
tive. Leucocyte  count,  30,000.  After  a  few  days  several  abscesses 
developed,  the  first  being  in  the  vulva,  and  were  opened.  Patient 
recovered  after  a  long  illness. 


PUEKPEEAL    SEPTIC    INFECTION 


471 


Brief  reference  is  made  to  this  case  on  account  of  the  leucocy- 
tosis.  Much  was  expected  a  few  years  ago  from  the  leucocyte 
count  as  an  aid  to  diagnosis  in  suspected  pus  formations.     The 


Fig.  164. — Leucocytosis. 

P,  polymorphnuclear ;  LM,  large  mononuclear  ;  SM,  small  mononuclear 
(W.  N.  Meldrum). 


results  of  investigations  were  in  many  respects  unsatisfactory, 
and  it  is  the  habit  of  many  now  to  belittle  the  significance  of 
such  count. 

I  think,  however,  we  may  obtain  much  assistance  from  the 
leucocyte  count  in  certain  cases.  The  following  facts  as  to  leu- 
cocytosis are  generally  admitted.  There  is  a  slight  leucocytosis  in 
pregnancy,  which  increases  for  two  or  three  days  after  labor  and 
then  decreases  up  to  the  end  of  the  first  week,  when  it  ceases. 
There  is  no  leucocytosis  in  a  large  proportion  of  cases  of  acute  sep- 
ticemia, especially  the  rapidly  fatal  forms.  There  is  generally 
leucocytosis  in  puerperal  infection  with  the  formation  of  abscesses. 
There  is  little  or  no  leucocytosis  with  some  forms  of  chronic  ab- 
scess, especially  those  due  to  tubercle  bacilli  and  gonococci.  A 
leucocytosis  of  20,000  to  30,000,  continuing  three  days,  generally 
indicates  pus  formation. 


472  LISTEEISM    AND    OBSTETEICS 

This  case  may  be  compared  with  that  reported  on  page  233,  a 
case  of  supposed  septic  infection  which  was  probably  typhoid  fever. 
It  seems  probable  in  certain  cases  that  a  marked  leucocytosis,  with 
negative  Widal  results,  furnish  strong  evidence  of  pus  formation, 
while  a  marked  leucopoenia,  with  a  positive  Widal  reaction,  will 
furnish  strong  evidence  of  typhoid  fever. 


CHAPTER  XXII 

PUERPERAL  INFECTION  (Continued) 
Phlegmasia  A  Iba  Dolens ;  Femoral  or  Crural  Phlebitis ;  Milk  Leg ;  White  Leg. 

This  is  a  peculiar  swelling  of  the  lower  extremity  (very  rarely 
the  upper  extremity),  white  in  appearance,  accompanied  with  great 
pain  and  general  constitutional  symptoms.  Occasionally  both  legs 
may  be  affected,  but  seldom  does  the  affection  begin  in  both  at  the 
same  time. 

The  symptoms  nearly  always  appear  in  second  or  third  week, 
although  before  this  time  there  have  been  some  of  the  premonitory 
signs  of  septicaemia,  such  as  headaches,  insomnia,  etc.  There  is 
very  severe  pain  during  the  acute  stage,  which  abates  after  the 
hard,  brawny  condition  gives  place  to  soft  oedema.  There  is  swell- 
ing, which  is  at  first  hard  and  brawny,  with  a  glistening  white  sur- 
face. It  commences  sometimes  in  the  thigh,  sometimes  in  the  leg, 
occasionally  in  the  neck  or  arm.  There  are  also  general  malaise, 
rapid  pulse,  increased  temperature,  and  usually  constipation. 

Coagula  are  generally  felt  along  the  course  of  the  veins.  The 
other  limb  may  become  similarly  affected.  The  acute  painful 
stage  lasts  a  week  to  a  fortnight. 

The  whole  duration  is  from  four  to  six  weeks — sometimes 
longer. 

Phlegmasia  alba  dolens  is  probably  always  due  to  mild  septic 
infection.  It  received  the  name  milk-leg  because  it  was  once 
thought  to  be  caused  by  a  metastasis  of  milk.  There  is  generally 
present  a  phlebitis  and  occasionally  a  celluHtis,  or  both  phlebitis  and 
cellulitis.  The  simple  thrombosis  of  the  veins  of  the  leg — some- 
times called  a  marantic  thrombosis — should  not  be  included.  It 
is  so  seldom  found  in  the  upper  extremity  that  many  authors  do 
not  mention  the  possibility  of  puerperal  phlegmasia  dolens  in  the 
arm  and  neck. 

Two  cases  have  come  under  my  observation,  and  Spence  of 
Toronto  has  reported  one  case.     My  first  case  caused  me  much 

473 


474 


PUEEPEEAL    INFECTION 


anxiety  for  a  couple  of  days.  The  patient  was  doing  fairly  well 
for  about  ten  days,  when  a  brawny  swelling  suddenly  appeared  in 
the  neck,  accompanied  with  very  severe  pain.  The  swelling  grad- 
ually extended  down  the  arm,  forearm,  hand,  and  fingers.     After 


Fig.  165. — Many-tailed  Bandage  on  the  Right.      T-bandage  on  the  Left, 


a  few  days  the  brawny  induration  changed  into  a  soft  oedema,  and 
the  pain  disappeared.  The  swelling  gradually  subsided  and  the 
arm  was  fairly  well  in  five  weeks,  although  it  remained  weak  for 
several  months. 

In  the  other  case  (Dr.  McPhedran's  patient)  phlebitis  appeared 
in  left  leg  and  thigh  one  week  after  labor,  in  the  right  leg  fifteen 
days  later,  and  left  side  of  neck  three  days  later.  The  swelling 
soon  extended  down  the  arm  to  fingers.  The  pain  in  neck  and  arm 
was  much  more  severe  than  that  in  the  legs.  Recovery  took  place 
in  reverse  order:  arm  first,  right  leg  second,  left  leg  third.  The 
illness  lasted  altogether  about  four  and  a  half  months. 

The  most  important  feature  from  a  therapeutic  standpoint  is 
the  extreme  pain  which  the  patient  suffers  during  the  time  of  the 
hard  brawny  swelling.  The  patient  should  get  large  doses  of  opium 
during  this  time.  If  the  pain  is  thus  kept  in  check,  I  think  as  a  rule 
the  length  of  the  illness  will  be  diminished.  Lotions  are  not  of 
much  service,  but  the  dry  poultice  should  always  be  applied.     In 


PULMON^ARY    EMBOLISM 


475 


doing  this  surround  the  Hmb  with  cotton  wool,  cover  with  oil  silk, 
and  keep  the  dressing  in  position  with  a  many-tailed  bandage, 
and  not  by  an  ordinary  roller  bandage  such  as  is  too  often  used. 
Keep  the  limb,  as  far  as  possible,  absolutely  at  rest  and  slightly 
elevated.  Do  not  use  friction  at  any  stage,  for  fear  of  separating 
a  portion  of  the  clot.  Keep  the  bowels  fairly  open  and  give  good 
food  and  strychnine. 

Pulmonary  embolism  is  one  of  the  possible  accidents  of  the 
puerperal  period.  Generally,  if  not  always,  there  has  been  a  pre- 
vious thrombosis  in  some  of  the  veins  of  the  pelvis  or  lower  limb. 
The  embolus,  after  it  is  broken  off,  travels  toward  the  heart,  and 
when  large  may  be  arrested  in  the  heart,  causing  sudden  death,  or 
it  may  pass  through  it  into  the  pulmonary  artery.  When  it  com- 
pletely blocks  the  main  trunk  of  this  artery-  it  causes  death,  as  a 
rule,  in  a  few  minutes.  When  a  smaller  plug  blocks  merely  a 
branch  of  the  pulmonary  artery  it  may  cause  severe  symptoms. 


Fig.  166. — Many-tailed   Bandage   Partially  Applied. 


but  the  patient  will  probably  recover.     When  the  embolus  is 
arrested  a  secondary  thrombosis  is  hkely  to  occur. 

Symptoms. — The  symptoms  generally  appear  suddenly  and  are 
so  well  marked  that  one  can  hardly  fail  to  recognize  them.  The 
patient  is  seized  with  the  most  intense  and  distressing  dyspna-a. 
She  gasps  and  struggles  for  breath.  Although  air  does  actually 
enter  the  lungs,  she  still  has  the  feeling  of  suffocation.  The  face 
generally  becomes  purple,  although  occasionally  it  is  pale.     The 


476 


PUERPEEAL    INFECTION 


action  of  the  heart  is  at  first  violent,  but  it  soon  becomes  weak  and 
irregular,  and  the  pulse  becomes  small,  rapid,  and  irregular. 
Death  may  occur  in  a  very  short  time.  A  patient  of  the  late  Dr. 
Burns,  who  was  apparently  doing  well,  had  a  sudden  seizure  fif- 
teen days  after  labor  and  died  in  about  five  minutes.  Dr.  John  L. 
Bray  had  three  similar  cases,  in  which  the  patients  died  in  nine, 
ten,  and  eleven  days  respectively,  after  labor.  Sometimes  after 
the  serious  symptoms  have  lasted  a  few  minutes  the  patient  gradu- 
ally improves  and  recovery  takes  place.  It  is,  of  course,  very 
important   to  keep  her  absolutely  quiet.      Stimulants,    such    as 


Fig.  167. — Many-tailed  Bandage  Applied  for  Phlegmasia   Dolens. 


whisky,  ether,  and  ammonia,  may  be  administered.  Oxygen  may 
be  inhaled.  Opium  should  be  given  after  the  urgent  symptoms 
have  subsided.  Venesection  may  be  performed  if  there  is  marked 
cyanosis. 

GONORRHCEAL   INFECTION 

Whatever  doubt  there  may  have  been  about  the  matter  in 
years  past,  it  is  now  generally  conceded  that  gonorrhoea  is  caused 
by  the  gonococcus.  Some  say  that  this  peculiar  germ  is  septic, 
while  others  deny  that  it  alone  can  produce  sepsis.  Galabin  says 
the  gonococcus  appears  to  be  capable  of  acting  on  certain  organ- 
isms under  certain  circumstances.  Mann  says  that  the  gonococci 
are  much  milder  and  slower  in  their  action  than  are  the  septic 
germs,  meaning,  I  presume,  that  the  former  are  not  alone  capable 
of  producing  sepsis. 


GONORRHCEAL    INFECTION  477 

Without  attempting  to  discuss  the  different  views,  I  shall  con- 
sider the  gonococcus  an  ordinary  septic  microbe.  We  know,  from 
clinical  observation,  that  gonorrhoea  produces  serious  results  in 
the  female,  and  therefore  we  are  inclined  to  look  upon  the  gonococ- 
cus as  the  direct,  or  indirect,  agent  in  the  production  of  such 
results.  The  parts  attacked  in  the  early  stages  are  the  vulva, 
urethra,  Bartholinian  glands,  cervical  canal,  and  perhaps  to  a  cer- 
tain extent  the  vagina. 

In  the  majority  of  cases  of  acute  gonorrhoea  the  disease  is  set 
up  in  the  cervix  and  vulva  at  the  same  time,  but  there  is  no  cer- 
tain rule  as  to  this,  and  it  not  infrequently  happens  that  the  cervix 
is  at  first  attacked  and  the  external  parts  afterward,  and  in  a  few 
cases  it  appears  that  only  the  vulvar  region  is  infected.  When  all 
the  acute  symptoms  have  disappeared  the  germs  may  still  be  pres- 
ent in  the  region  of  the  urethral  orifice,  in  the  ducts  of  the  Bartho- 
linian glands,  and  in  the  cervix. 

The  disease  is  apt  to  extend  slowly  along  the  genital  tract,  ex- 
tending upward  from  the  cervix,  along  the  uterine  mucosa,  along 
the  Fallopian  tubes,  and  perhaps  into  a  small  portion  of  the 
peritoneal  cavity.  It  fortunately  happens  that  it  does  not  spread 
to  this  extent  in  the  majority  of  cases.  It  is  also  a  fortunate 
circumstance  that  its  progress  is  very  slow,  as  the  disease  in  any 
case  is  not  likely  to  reach  the  tubes  in  less  than  six  weeks  to  two 
months.  It  is  said  that  it  has  been  known  to  reach  the  tubes  in 
ten  days  after  infection.  While  I  do  not  deny  the  possibility  of 
this,  I  think  such  cases  must  be  very  rare.  According  to  Schmitt, 
as  quoted  by  Herman,  gonorrhoea  extends  to  the  uterus  in  about 
one  case  in  five,  and  to  the  tubes  in  about  one  case  in  twenty. 

The  most  important  site  of  infection,  from  an  obstetrical  point 
of  view,  is  the  cervical  canal.  The  germs  may  lie  in  this  canal  for 
months  or  even  years.  They  often  lie  here  during  the  whole  of 
pregnancy  without  any  attempt  to  spread.  After  labor  the  con- 
ditions are  entirely  changed,  and  the  germs,  which  were  before  ap- 
parently asleep,  become  actively  wide  awake.  This  is  probably 
due  to  the  fact  that  the  lochia  afford  a  good  culture  medium  for 
the  germs,  which,  under  the  new  conditions,  thrive,  multiply,  and 
spread  until  they  have  traversed  the  entire  genital  tract.  Nature 
steps  in  here  in  a  very  remarkable  way  to  prevent  these  germs  from 
going  far  beyond  the  tubes.  We  have  the  salpingitis  and  fre- 
quently ovaritis,  but,  generally  speaking,  the  pavilion  of  the  tube 


478  PUERPEEAL    INFECTION 

is  sealed  up  by  adhesive  inflammation.  Pryor  says  that  we  have 
a  gluing  together  of  the  fimbriae,  or  else  an  attachment  of  the  tube 
to  some  adjacent  structure,  usually  the  ovary,  which  causes  the 
occlusion  of  the  tube.  But  he  adds  that  generally  the  uterine  end 
of  the  tube  is  also  occluded.  We  thus  have  the  tube  entirely  shut 
off  not  only  from  the  peritoneal,  but  also  from  the  uterine  cavity. 
One  of  the  effects  of  such  occlusion  of  both  tubes  is  sterility.  In 
many  cases  a  woman  becomes  infected  during  her  first  pregnancy ; 
such  infection  more  frequently  occurs  probably  early  in  pregnancy, 
although  it  may  happen  at  any  time.  If  early,  the  acute  symp- 
toms will  have  passed  away  probably  in  a  few  weeks  and  the  germs 
will  be  situated  in  the  lower  part  of  the  cervical  canal.  After  labor 
double  salpingitis  sometimes  occurs,  producing  a  condition  called 
by  Sanger  "one-child  sterility." 

Some  obstetricians  justly  dread  the  presence  of  gonorrhoea, 
especially  at  or  near  the  time  of  labor,  and  if  puerperal  infection 
takes  place  during  the  first  week  after  labor  they  are  apt  to  think 
that  it  is  caused  by  the  gonorrhoea.  The  gonococcus  cannot, 
however,  cause  the  infection  in  so  short  a  time.  Nor  does  it  do  so 
even  when  the  patients  have  a  copious  gonorrhoeal  discharge  dur- 
ing labor.  Sanger  found  in  the  Leipzig  Clinic  that  26  per  cent,  of 
pregnant  women  had  gonorrhoea ;  Oppenheimer,  in  the  Heidelberg 
Clinic,  found  27  per  cent. ;  Lohmer,  in  Berlin,  found  28  per  cent. 
These  observers  all  agree  that,  notwithstanding  the  large  propor- 
tion of  women  infected  with  gonorrhoea,  the  mortality  in  all  the 
hospitals  was  small,  showing  that  gonorrhoea  has  but  little  effect 
in  the  early  weeks  after  labor,  and  seldom  or  never  causes  the 
ordinary  puerperal  infection.  In  fact,  Sanger  says  that  a  gonor- 
rhoeal woman  runs,  in  the  first  few  weeks  after  labor,  little  more 
risk  of  septic  infection  than  any  other  puerperal  woman.  Pryor, 
after  quoting  Sanger  as  above,  says  that  when  she  has  ceased  to  be 
puerperal  she  becomes  liable  to  complications  incident  to  gonor- 
rhoea. He  points  out,  as  was  before  shown  by  Baumm  and  Fenger, 
that  the  squamous  epithelium  of  the  adult  vagina,  the  endometrium 
of  the  puerperium,  and  also  the  endometrium  of  the  nulliparous 
uterus,  have  great  resistant  power  against  the  spread  of  gono- 
cocci.  He  adds  that  gonorrhoea  runs  a  shorter  course  in  the  female 
than  in  the  male  and  with  less  risk  of  complications.  Fenger,  in 
referring  to  the  fact  that  a  general  peritonitis  rarely  or  never 
occurs  from  gonorrhoea,  says  that  Mercier  reports  a  typical  case  of 


GONOERHCEAL    INFECTION  479 

a  strumpet  who  died  while  suffering  from  gonorrhoea.  The  autopsy- 
showed  the  uterus  deeply  infected,  tubes  distended  by  muco-pus, 
the  fimbrisB  closely  adherent,  and  the  peritoneum  healthy. 

Therefore,  if  we  care  for  our  patient  during  labor  in  a  cleanly 
way,  we  shall  not  find  any  evil  results  from  the  gonorrhoeal  infec- 
tion for  some  weeks ;  but  if  we  introduce,  or  allow  to  be  introduced, 
any  streptococci  or  any  staphylococci,  we  have  reason  to  believe 
that  we  shall  then  have  a  mixed  infection,  in  which  the  two  forms 
of  germs  will  materially  aid  each  other  in  their  destructive  ravages. 
As  pointed  out  by  Mann,  the  pure  gonorrhoeal  infection  usually 
shows  itself  in  the  third  or  fourth  week,  whereas  the  mixed  infec- 
tion develops  soon  after  labor. 

We  must  not  conclude  from  these  facts  that  the  gonorrhoea 
does  not  produce  serious  and  lasting  results.  Salpingitis,  ovaritis, 
and  the  other  inflammations  in  the  neighborhood  of  the  uterus, 
produce  at  least  two  very  serious  results,  the  first  being  the  con- 
dition of  sterility,  the  second  being  the  more  serious  condition  of 
permanent  loss  of  health. 

Pus  Tubes. — We  hear  much  about  pus  tubes,  and  I  fear  that 
many  of  our  physicians  and  surgeons  have  only  hazy  or  incor- 
rect ideas  as  to  their  cause  and  results.  Some  have  talked  of  pus 
tubes  as  if  they  were  always  produced  by  gonorrhoea.  Gonorrhoea, 
in  a  certain  proportion  of  cases,  does  certainly  cause  pus  tubes ;  and 
I  have  studied  statistics  pretty  carefully  in  order  to  find  its  prob- 
able frequency  as  a  cause.  So  far  as  I  have  learned,  I  can  find  no 
careful  observer  who  considers  that  gonorrhoea  is  the  cause  of  pus 
tubes  in  more  than  20  to  30  per  cent,  of  all  cases.  The  most  com- 
mon cause  is  septic  infection  after  abortion  or  labor. 

It  may  be  added  in  connection  with  this  subject,  that  pus  tubes 
due  to  gonorrhoeal  infection  never  cause  puerperal  fever.  There 
has  been  a  great  deal  of  confusion  in  the  past  about  the  germs 
found  in  these  purulent  collections  in  the  tubes.  In  a  fairly  large 
proportion  of  cases  no  organisms  of  any  sort  can  be  found.  This 
is  due  to  the  fact  that  bacteria  confined  and  encapsulated  in  closed 
pus  cavities  soon  lose  their  virulence;  they  die  from  their  own 
products,  the  toxines.  The  average  time  in  which  the  pus  thus 
becomes  sterile  is  about  nine  months. 


32 


CHAPTER  XXIII 

DEFORMITIES  OF   THE  BONY  PELVIS  AND  INJURIES   TO 
THE  CHILD  DURING  DELIVERY 

Deformities  of  the  pelvis  include  all  variations  from  the  size 
and  shape  of  the  normal  pelvis. 

These  variations  are  nearly  always  contractions.  No  others 
need  be  considered. 

The  contractions  which  affect  labor  are  chiefly  those  at  the 
brim. 

The  most  important  of  these  is  contraction  of  the  antero- 
posterior or  conjugate  diameter. 

CAUSES   AND    FORMS    OF    DEFORMITY 

The  causes  and  varieties  generally  recognized  are  as  follows : 
Causes. — 1.  Rickets — producing  changes  in  the  shape  of  the 
pelvis  in  early  life  before  the  bones  are  properly  ossified. 

2.  Osteomalacia — producing  changes  in  adult  life  through  soft- 
ening of  bones  that  have  been  properly  ossified.  Much  less  com- 
mon than  rickets. 

3.  Displacement  of  bones  in  or  near  the  pelvis,  such  as  forward 
and  downward  displacement  of  lower  lumbar  vertebrae  (spondylo- 
listhesis), and  displacements  of  sacrum  from  curvature  of  spine. 

4.  Diseases  of  the  pelvic  bones  from  tumors,  etc. 

5.  Interference  with  normal  development  of  the  pelvis  pro- 
ducing the  infantile  pelvis. 

The  more  common  forms  are : 

1.  Flattened  pelvis. 

2.  Generally  contracted  pelvis,  including  the  dwarf  pelvis. 

3.  Obliquely  distorted  pelvis. 

4.  Spondylolisthetic  pelvis. 

5.  Transversely  contracted  pelvis  (Roberts's  pelvis). 
480 


CAUSES    AND    FORMS    OF    DEFORMITY  481 

6.  Funnel-shaped  pelvis  (masculine  pelvis). 

7.  Rhachitic  pelvis. 

8.  Osteomalacic  pelvis. 

9.  Deformity  from-  tumors,  exostosis,  etc. 

Flattened  pelvis  is  the  most  common  form  of  pelvic  deformity 
in  Canada.  In  the  majority  of  cases  the  patients  do  not  show  any 
traces  of  rickets,  which  is  so  commonly  the  cause  in  some  coun- 
tries. It  is  probably  acquired  during  early  life  in  some  cases, 
while  it  seems  to  be  the  result  of  a  congenital  condition  in  others. 
The  important  feature  is  the  shortening  of  the  conjugate  diameter 
— i.  e.,  the  antero-posterior  diameter  at  the  brim.  It  sometimes 
happens  that  a  flat  pelvis  is  also  "  generally  contracted." 

Generally  contracted  pelvis  comes  second  in  frequency  as  a  form 
of  pelvic  deformity  in  Canada.  Under  this  term  are  included  the 
pelvis,  which  is  equally  and  slightly  contracted  in  all  parts,  and 
also  what  is  called  the  dwarf  pelvis.  The  difference  between  the 
two  is  chiefly  one  of  degree,  but  in  most  of  the  dwarf  pelves  the 
word  sequabiliter  cannot  be  used  in  describing  the  contraction. 

Obliquely  distorted  pelvis  is  by  no  means  uncommon  in  this  or 
any  other  country.  There  is  in  this  deformity  a  deviation  of  a 
part  or  the  whole  of  the  pelvis  toward  one  side,  causing  a  marked 
difference  in  the  length  of  the  oblique  diameters  in  all  the  planes 
of  the  pelvis.  One  form  is  called  Naegele's  pelvis,  in  which  the  dis- 
tortion is  caused  by  unilateral  disease,  fracture,  or  failure  of  devel- 
opment in  the  region  of  one  sacro-iliac  joint.  Among  other  causes 
of  the  obliquely  distorted  pelvis  are  the  various  forms  of  spinal 
curvature,  coxalgia,  and  unequal  lengths  of  legs. 

Spondylolisthetic  pelvis  is  due  to  the  forward  and  downward 
displacement  of  the  fifth  lumbar  vertebra. 

Transversely  contracted  pelvis  or  Roberts's  pelvis  consists  in 
symmetrical  narrowing  and  antero-posterior  elongation  of  the  pel- 
vis.    It  is  considered  by  some  to  be  a  sort  of  double  Naegele. 

Funnel-shaped  pelvis  is  one  whose  internal  diameters  diminish 
from  the  inlet  to  the  outlet. 

Rhachitic  Pelvis.  The  most  common  form  of  this  is  the  rha- 
chitic flat  pelvis,  which  usually  results  from  early  rickets  before  the 
child  walks.  The  patient  is  generally  below  medium  height,  with 
a  pendulous  abdomen  and  clumsy  gait.  The  iliac  crests  are 
everted  in  front  so  that  the  interspinous  diameter  is  relatively 
lengthened  and  is  equal  to  or  greater  than  the  intercristal. 


482  DEFOEMITIES    OF    THE    BONY    PELVIS 

Osteomalacic  pelvis  or  malacosteon  is  caused  by  a  disease  called 
osteomalacia,  which  does  not  occur  in  Canada,  so  far  as  I  know, 
but  is  endemic  in  certain  parts  of  Europe  and  other  countries  with 
hot  climates.  The  disease  causes  extreme  softening  of  the  bones 
in  adults,  and  frequently  extreme  deformity  of  the  pelvis. 

Deformity  from  Tumors,  Exostoses,  etc.  Various  bony  tumors, 
both  simple  and  malignant,  in  the  pelvis  cause  serious  obstruction 
to  labor.  Simple  bony  tumors  include  exostoses,  ossifications  of 
insertions  of  ligaments  and  tendons,  masses  of  callus,  results  of 
rheumatoid  arthritis,  etc.  Malignant  tumors  of  the  bone  are  gen- 
erally sarcomata,  but  occasionally  carcinomata.  They  are  most 
likely  to  cause  serious  obstruction,  because  they  grow  very  rapidly 
during  pregnancy. 

CONTRACTED  PELVIS 

The  following  conditions  indicate  the  probability,  or  at  least 
the  possibility,  of  contracted  pelvis : 

Extreme  smallness  of  figure. 

Kyphosis  (curvature  of  spine  with  convexity  posterior). 

Scoliosis  (lateral  curvature  of  the  spine). 

Lordosis  (curvature  of  spine  with  convexity  anterior). 

Unequal  length  of  legs. 

Pendulous  abdomen. 

Difficult  previous  labor. 

Variations  from  normal  labor,  such  as : 

Premature  rupture  of  the  membranes. 

Prolapse  of  the  cord. 

Non-engagement  of  the  head  in  the  pelvis. 

Descent  of  the  large  fontanelle  with  sagittal  suture  in  trans- 
verse diameter  of  the  brim. 

Striking  descent  of  the  small  fontanelle,  as  in  generally  con- 
tracted pelvis. 

An  extremely  small  woman  generally  has  a  small  pelvis;  a 
woman  with  marked  curvature  of  the  spine,  with  one  leg  shorter 
than  the  other  or  with  pendulous  belly,  generally  has  a  distorted 
or  contracted  pelvis.  A  patient  showing  any  such  conditions 
should  be  examined  very  carefully.  If  there  is  a  dwarf  pelvis  or 
an  extreme  contraction  of  any  sort,  one  can  quickly  come  to  a 
decision.  The  greatest  difficulties  as  to  passing  judgment  will 
arise  in  the  minor  degrees  of  contraction,  when  one  has  to  con- 


CONTRACTED    PELVIS  483 

sider  such  alternatives  as  induction  of  premature  labor,  version, 
forceps  delivery — or,  to  go  a  little  farther,  symphysiotomy,  ab- 
dominal section,  and  embryotomy — and  make  a  proper  choice. 

Variations  from  Normal  Labor. — The  variations  of  special 
importance  are  noii-cngagcnient  of  the  head  in  the  pelvis  and 
abnormality  as  to  either  fontanelle.  When  one  can  easily  feel 
the  large  or  anterior  fontanelle  there  is  always  something  abnor- 
mal. It  is  generally  satisfactory  to  be  able  to  feel  the  small  or 
posterior  fontanelle  after  labor  has  advanced  to  a  certain  extent, 
but  it  is  not  satisfactory  to  be  able  to  reach  it  early  in  labor  while 
the  head  is  at  the  brim.  Some  obstetricians  attach  considerable 
importance  to  this  and  designate  it  posterior  fontanelle  presenta- 
tion, as  distinguished  from  vertex  presentation.  It  means  undue 
or  extreme  flexion  before  the  head  has  entered  or  when  it  is  enter- 
ing the  brim.  This  abnormal  position  is  commonly  produced  by 
a  generally  contracted  pelvis  causing  sufficient  obstruction  to 
produce  the  early  flexion,  but  it  is  also  produced  in  the  case  of  a 
very  large  foetal  head  coming  into  a  normal  pelvis. 

Mechanism  of  Head  Presentation  in  a  Flattened  Pelvis. — This 
may  be  briefly  described  as  follows : 

The  long  occipito-frontal  diameter  of  the  head  is  in  the  trans- 
verse diameter  of  the  brim. 

As  the  head  descends  the  posterior  parietal  bone  is  partially 
stopped  by  the  promontory,  causing  the  head  to  rotate  on  its 
antero-posterior  axis,  inclining  a  side  of  the  head  toward  the  cor- 
responding shoulder.  As  a  result  the  sagittal  suture  approaches 
the  promontory  and  the  anterior  parietal  bone  lies  lowest. 

This  is  sometimes  called  Naegele's  obliquity  or  anterior  parietal 
'presentation. 

The  head  is  caught  between  the  sacrum  and  symphysis  in 
front  of  the  parietal  eminence.  Flexion  is  thus  prevented  and 
some  extension  takes  place. 

The  posterior  parietal  bone  generally  rounds  the  promontory, 
is  grooved  vertically,  and  occasionally  fractured. 

In  a  small  proportion  of  cases  the  posterior  parietal  bone  lies 
lowest  and  the  sagittal  suture  approaches  the  pubes.  The  anterior 
parietal  then  rounds  the  symphysis,  the  posterior  parietal  being 
grooved  as  in  the  other  case.  The  posterior  parietal  presentation 
is  much  less  favorable  than  the  anterior. 

As  soon  as  the  head  passes  through  the  brim  the  occiput 


484  DEFOEMITIES    OF    THE    BONY    PELVIS 

rotates  to  the  front  and  delivery  is  completed  as  in  the  ordinary- 
vertex  presentations  in  the  normal  pelvis. 

Mechanism  of  Head  Presentation  in  a  Generally  Contracted 
Pelvis. — The  extreme  flexion  of  the  head  making  the  posterior 
fontanelle  the  presenting  part  at  the  brim  is  the  chief  feature  of 
the  mechanism,  as  before  mentioned.  Apart  from  this  there  is 
nothing  special  to  note.  If  the  contraction  is  not  too  great  in 
proportion  to  the  size  of  the  head,  the  mechanism  is  similar  to 
that  of  vertex  presentation. 

TREATMENT 
Minor  Degrees  of  Contraction. — Opinions  vary  greatly  as  to 
the  proper  treatment  in  cases  of  slight  contraction  of  the  pelvis — 
i.  e.,  when  the  true  conjugate  measures  4  to  3^  inches.  I  had  a 
patient  a  year  ago  pregnant  for  the  third  time  and  supposed  to 
have  marked  contraction  of  the  pelvis.  Ten  years  ago  symphysi- 
otomy at  full  term  was  performed  by  Drs.  Atherton  and  Burns 
and  a  healthy  child  (still  living)  was  extracted  with  the  forceps. 
During  her  second  pregnancy  she  was  under  the  care  of  physicians 
in  Charleston,  S.  C,  who  induced  premature  labor  at  the  end  of 
the  seventh  month.  The  child  was  born  alive,  but  died  in  a  short 
time.  In  her  third  pregnancy  she  came  to  Toronto  (her  home  in 
girlhood)  when  six  months  advanced.  After  careful  measurements, 
using  Shultze's  instrument  for  external  pelvimetry,  and  fingers 
and  Skutsch's  instrument  for  internal,  I  concluded  that  there  was 
slight  general  contraction  without  any  flattening,  and  decided  to 
watch  her  carefully  and  induce  premature  labor  if  at  any  time 
it  seemed  advisable.  I  thought  that  interference  would  not  be 
necessary  before  the  end  of  the  eighth  month  and  hoped  she  might 
go  on  to  full  term.  As  the  head  could  always  be  pressed  into  the 
brim  there  was  no  interference  until  labor  commenced  about  one 
week  after  the  expected  date.  The  vertex  presented — O.  L.  A. — 
the  head  had  entered  the  pelvis  when  I  first  examined  her.  At 
the  proper  time  she  was  anesthetized,  and  a  well-formed  living 
child  weighing  six  and  a  half  pounds  was  extracted  with  forceps 
without  any  special  difficulty.  The  child  died  shortly  after  birth, 
from  what  cause  I  do  not  know. 

It  is  not  often  that  one  patient  in  three  successive  pregnancies 
gets  such  varied  methods  of  treatment.  One  can  not  give  a  pos- 
itive opinion  without  knowing  particulars  as  to  whether  symphysi- 


CONTEACTED    PELVIS  485 

otomy  was  necessary  or  advisable  ten  years  ago;  but  certainly 
it  was  justifiable,  and  the  results  were  eminently  satisfactory  in 
all  respects.  Similarly  one  cannot  say,  without  knowing  partic- 
ulars, whether  the  induction  of  premature  labor  was  necessary  or 
advisable  in  the  second  pregnancy;  but  it  is  always  a  pity  to 
have  to  deliver  a  foetus  at  the  end  of  the  seventh  month.  Each 
week  thereafter  during  the  eighth  and  ninth  months,  under  ordi- 
nary circumstances,  increases  the  vigor  of  the  child.  In  the  third 
pregnancy  it  was  easy  to  discover  that  the  induction  of  premature 
labor  was  not  necessary  at  any  time  in  the  eighth  or  the  first 
half  of  the  ninth  month. 

The  following  general  directions  as  to  treatment  in  minor 
degrees  of  contraction  may  be  given. 

When  it  is  known  or  even  suspected  that  the  patient  has  pelvic 
contraction,  an  examination  should  be  made  at  the  end  of  the 
seventh  month,  and,  if  necessary,  every  week  or  ten  days  there- 
after until  it  is  found  that  the  head  can  not  be  made  to  enter  or 
engage  in  the  brim. 

Use  Miiller's  method  as  follows:  Place  the  patient  in  the 
cross-bed  position ;  introduce  one  or  two  fingers  into  the  vagina 
and  palpate  the  head.  Then  let  an  assistant  grasp  the  head 
through  the  abdominal  wall  and  try  to  push  it  down  through  the 
brim.  If  he  succeeds,  the  induction  of  labor  is  not  necessary. 
If  in  the  next  trial  the  head  can  not  be  pushed  through  the  brim, 
labor  should  be  induced  at  once.  Miiller's  method  is  the  best, 
but  one  can  sometimes  push  the  head  through  the  brim  when  the 
patient  is  lying  in  the  ordinary  semirecumbent  position  and  be 
sure  of  doing  so  without  an  internal  examination. 

The  cervix  frequently  dilates  slowly  or  imperfectly,  rendering 
artificial  assistance  necessary  or  advisable. 

In  the  second  stage  allow  the  head  to  "mold"  at  the  brim 
for  one  hour.  If  it  engages  in  the  brim,  allow  it  to  mold  for  two 
hours  longer,  during  which  time  it  will  probably  be  pushed  through 
the  brim.  If  delivery  has  not  been  accomplished,  apply  the  for- 
ceps in  accordance  with  the  rule  that  the  second  stage  should  not 
be  allowed  to  last  longer  than  one  to  three  hours. 

If  at  the  end  of  one  hour  the  head  shows  no  tendency  to  engage 
the  brim,  turn  and  treat  as  an  ordinary  pelvic  presentation. 

Forceps  versus  Version  in  Slightly  Contracted  Pelvis. — It  was 
formerly  generally  supposed  that  the  disadvantage  of  forceps  as 


486  DEFORMITIES    OF    THE    BONY    PELVIS 

compared  with  version  was  the  bulging  of  the  parietals  in  the 
conjugate  during  traction.  Milne  Murray  and  Porter  Mathew 
have  shown  clearly  by  certain  experiments  that  such  bulging  does 
not  take  place  because  the  child's  head,  instead  of  being  a  continu- 
ous elastic  box,  is  made  up  of  segments  which,  under  pressure, 
glide  under  and  over  one  another.  It  may  be  admitted  that 
when  it  is  possible  to  extract  a  living  child  version  has  no  advan- 
tage over  good  axis-traction  forceps  properly  applied,  and  in  the 
interest  of  the  child  forceps  delivery  has  some  (not  ''every") 
advantage.  It  has  been  demonstrated  that  much  can  now  be 
done  with  the  axis-traction  which  could  not  formerly  be  accom- 
plished with  the  ordinary  long  forceps. 

It  unfortunately  happens,  however,  that  the  application  of 
the  forceps  to  a  head  which  has  not  engaged  in  the  brim  is  exceed- 
ingly difficult  as  well  as  dangerous  in  the  majority  of  cases  to 
both  mother  and  child,  although  such  dangers  are  lessened  in  the 
hands  of  experts  who  have  become  skilled  by  considerable  prac- 
tice. Turning  is  easier  of  performance  and  safer,  as  a  rule,  than 
the  high  forceps  operation,  and  should  be  the  operation  of  election 
when  the  head  is  above  the  brim.  When  the  head  has  partially 
engaged,  but  the  greatest  diameter  of  the  head  is  still  above  the 
brim,  it  is  not  easy  to  give  a  fixed  rule.  If  one  has  waited  three 
hours  for  the  head  to  mold  and  finds  the  head  has  engaged  well, 
even  though  not  certain  as  to  the  position  of  its  greatest  diameter, 
he  should  apply  the  forceps  and  use  traction  with  the  patient  in 
Walcher's  position. 

If  in  any  case  the  accoucheur  has  properly  applied  the  for- 
ceps so  that  they  hold  and  is  unable  to  bring  the  head  down, 
he  should  not  on  any  account  attempt  version.  Jardine,  who 
has  had  a  varied  and  extensive  experience  in  difficult  obstet- 
rical cases  in  the  Glasgow  Maternity  Hospital,  tells  us  that 
most  of  the  cases  of  rupture  of  the  uterus  have  been  caused  by 
such  procedures. 

While  the  general  rule  should  be  to  turn  when  the  head  has  not 
engaged,  there  should  be  certain  exceptions.  One  should  not  turn 
when  rupture  of  the  uterus  is  threatening,  or  when  there  is 
tetanic  contraction  of  a  uterus  from  which  the  waters  have  long 
escaped.  Under  complete  anaesthesia,  however,  the  tetanic  con- 
traction may  wholly  or  partially  disappear.  I  have  turned  in  a 
number  of  cases  of  shoulder  presentation  after  I  found  the  uterine 


CONTRACTED    PELVIS  487 

walls  grip  the  foetus  very  tightly,  and  have  often  been  surprised 
at  the  marked  change  produced  by  anaesthesia  and  the  ease  with 
which  I  accompUshed  my  task. 

Mechanical  Advantages  of  Turning. — (1)  After  turning,  the 
narrower  bitemporal  diameter  is  first  engaged  in  the  contracted 
conjugate.  (2)  The  head  of  the  child  is  shaped  like  a  cone,  the 
narrowest  portion  being  the  base  of  the  cranium.  After  turning, 
the  apex  of  the  cone  is  brought  first  into  the  contracted  brim,  and 
can  be  more  easily  pulled  through  than  the  broader  base  of  the 
cone  can  be  pushed  through  by  the  uterine  contractions  or  pulled 
through  by  the  forceps.  Some  obstetricians  do  not  attach  much 
importance  to  these  points. 

Dublin  method.  In  flattened  pelvis,  the  true  conjugate  measur- 
ing 4  to  3-2^  inches,  or  in  generally  contracted  pelvis  measuring  4  to 
3f  inches,  the  Rotunda  obstetricians  do  not  apply  the  forceps 
when  the  head  is  above  the  brim.  Their  choice  is  between  pro- 
phylactic version  and  leaving  the  head  to  mold.  I  do  not  know 
their  precise  rules  as  to  choice  between  the  two.  According  to 
Jellett,  when  they  decide  to  allow  the  head  to  mold  through  the 
brim  of  itself  the  only  special  assistance  they  can  render  is  by  plac- 
ing the  patient  on  the  correct  side.  In  a  generally  contracted 
pelvis,  she  should  lie  upon  the  side  at  which  the  posterior  fontanelle 
is,  in  order  to  favor  its  descent.  In  a  flat  pelvis,  she  should  lie  at 
first  upon  the  side  at  which  the  forehead  is,  in  order  to  favor  the 
descent  of  the  anterior  fontanelle,  and  as  soon  as  this  takes  place 
upon  the  opposite  side  to  favor  the  descent  of  the  occiput.  With 
such  exceptions  they  leave  the  case  to  Nature  until  signs  of 
danger  to  the  mother  or  child  appear.  In  such  cases  they  may 
apply  the  forceps.  They  do  not  as  a  rule  apply  the  forceps  until 
the  head  has  passed  the  site  of  contraction.  In  case  of  failure 
with  forceps,  or  if  the  child  is  dead,  they  perforate. 

There  is  one  very  unsatisfactory  feature  in  this  line  of  treat- 
ment. It  occasionally  means  craniotomy  on  a  living  child.  This 
is  the  most  horrible  operation  in  the  whole  range  of  obstetrical 
surgery,  and  probably  most  of  us  think  it  should  never  be  per- 
formed. The  Roman  Catholic  Church  forbids  its  performance, 
for  which  I  honor  her.  If,  however,  we  have  left  our  case  to 
Nature  for  a  considerable  time,  then  applied  forceps,  but  failed  to 
deliver  the  living  child,  what  are  we  to  do?  We  may  regret  that 
we  did  not  before  decide  on  Csesarean  section.     We  may  now 


488  DEFOEMITIES    OF    THE    BONY    PELVIS 

perform  this  operation,  but  the  chances  for  our  patient's  recovery 
will  have  been  much  lessened  on  account  of  our  delay.  There 
seems  to  be  a  general  consensus  of  opinion  now  that  Caesarean 
section  should  be  done  before  or  in  the  beginning  of  labor,  and 
not  after  we  have  tried  other  methods,  such  as  version  or  traction 
with  forceps.  Under  such  circumstances  symphysiotomy  is  con- 
sidered by  some  the  most  suitable  operation. 

If  we  are  unable  to  complete  delivery  after  a  reasonable  trial 
of  the  ordinary  methods,  the  child  being  aHve,  and  advise  Caesa- 
rean section  or  symphysiotomy,  and  if  the  patient  and  her  hus- 
band refuse  consent,  what  shall  we  do?  In  the  Rotunda,  under 
such  circumstances,  they  perform  craniotomy. 

Treatment  in  the  second  degree  of  contraction  when  the  true 
conjugate  measures  3^  to  3  inches.  This  degree  of  contraction  is, 
I  think,  very  uncommon  in  Canada.  Many  believe  that  the  induc- 
tion of  premature  labor  is  the  best  treatment  if  one  sees  the  patient 
sufficiently  early  in  pregnancy.  If  one  does  not  see  the  patient 
before  the  advent  of  labor,  the  choice  lies  between  version,  use  of 
forceps,  symphysiotomy,  Caesarean  section,  and  craniotomy.  The 
chances  of  delivering  a  child  of  average  size  alive  either  by  version 
or  by  use  of  forceps  are  not  good;  but  the  chances  of  delivering 
a  small  child  by  either  method  are  at  least  fair.  Delivery  by 
either  method  is  possible  with  a  conjugate  of  2|  inches  if  the 
child  is  small. 

Treatment  in  the  third  stage  of  contraction  with  a  conjugate 
of  3  to  2  inches.  A  symphysiotomy  is  of  doubtful  utility  with 
a  conjugate  under  3  inches,  but  it  sometimes  gives  good  results 
down  to  2|  inches.  It  is  not,  as  a  rule,  justifiable  with  a  conjugate 
less  than  2|  inches.  After  symphysiotomy  the  only  alternatives 
are  Caesarean  section  or  embryotomy. 

Treatment  in  the  fourth  degree  of  contraction  with  a  conju- 
gate of  2  inches  or  less.  Caesarean  section  is  the  only  justifiable 
or  possible  operation.  Extraction  of  even  a  mutilated  child  is 
either  impossible  or  accompanied  with  serious  difficulty  and  great 
danger  to  the  mother. 

Summary  of  Rules  for  Treatment. — Treatment  in  minor  degrees 
of  contraction  with  true  conjugate  4  to  3^  inches  (10  to  8  cm.). 

During  Pregnancy.  Examine  patient  every  week  or  ten  days 
during  eighth  and  ninth  months  to  ascertain  when  the  head  can- 
not be  pushed  into  brim.     Then  induce  labor. 


INJURIES    TO    CHILD    DURING    DELIVERY       489 

During  Labor.  Perform  version  as  soon  as  possil^le  and  treat 
as  an  ordinary  breech  case;  or,  allow  the  head  to  mold  through 
the  brim  and  let  Nature  complete  the  delivery ;  or,  allow  head  to 
mold  two  or  three  hours,  and  then  use  forceps. 

In  second  degree  of  contraction  with  true  conjugate  3:^  to  3 
inches  (8  to  7  cm.) :  Induce  premature  labor  at  end  of  seventh 
month;  or,  perform  symphysiotomy;  or,  perform  Csesarean  sec- 
tion; or,  perforate  if  child  is  dead. 

In  third  degree  of  contraction  with  true  conjugate  3  to  2  inches 
(7  to  5  cm.) :  Perform  symphysiotomy  ( ?) ;  or,  perform  Csesarean 
section;  or,  perforate  if  child  is  dead. 

In  fourth  degree  of  contraction  with  true  conjugate  below  2 
inches  (5  cm.) :  Perform  Caesarean  section. 

INJURIES  TO  CHILD  DURING  DELIVERY 

Caput  Succedanaeum. — This  is  simply  a  serous  infiltration  of 
that  portion  of  the  presenting  part  which  corresponds  to  the  exter- 
nal OS.  The  lump  is  largest  immediately  after  birth,  and  usually 
disappears  in  three  or  four  days.     It  requires  no  treatment, 

CephaLhaematoma. — This  is  an  effusion  of  blood  between  the 
pericranium  and  the  bone  in  any  part  of  the  vault  of  the  cranium. 
It  occurs  about  once  in  two  hundred  labors.  In  rare  cases  the 
blood  is  effused  under  the  occipito-frontalis  tendon.  When  the 
blood  is  effused  under  the  pericranium,  it  cannot  extend  beyond 
the  bone  over  which  the  effusion  occurs.  The  swelling  is  generally 
found  in  the  situation  of  the  caput  succedanaeum  and  is  occasion- 
ally double.  After  a  time  a  bony  ridge  is  found  round  the  edge 
of  the  swelling.  The  whole  lump  sometimes  becomes  hard  and 
bony.  It  is  distinguished  from  the  caput  succedanaeum  by  the 
fact  that  it  is  not  present  immediately  after  birth,  by  its  fluctua- 
tion, its  long  persistence,  and  its  limitation  to  one  bone ;  and  from 
a  meningocele,  because  the  latter  is  situated  over  a  fontanelle  or 
suture  and  swells  when  the  child  cries. 

Treatment.  Do  not  interfere  with  it  in  any  way.  Spontaneous 
cure  takes  place  in  from  fifteen  days  to  two  months  in  the  great 
majority  of  cases.  If,  however,  it  becomes  painful,  or  persists 
more  than  two  months  and  still  appears  soft,  Treeves  advises 
aspiration  of  the  mass  and  the  application  of  firm  pressure.  I 
have  never  found  such  interference  necessary  or  advisable. 


490  DEFOKMITIES    OF    THE    BONY    PELVIS 

Depressions  of  the  skull  sometimes  occur,  especially  during 
artificial  delivery.  They  are  most  frequently  produced  by  the 
promontory  of  the  sacrum,  some  other  bony  prominence,  or  by  the 
forceps.  They  are  cup-shaped,  spoon-shaped,  or  furrow-shaped, 
and  are  most  frequently  found  on  the  anterior  part  of  the  parietal 
or  on  the  frontal  bone. 

Treatment.  Apply  pressure  to  the  head  obliquely.  The  de- 
pression will  thus  disappear  quickly  sometimes.  In  other  cases 
the  depression  gradually  disappears  in  a  few  days  or  a  few  weeks. 
When  the  depression  does  not  disappear,  but  causes  serious  symp- 
toms, surgical  interference  becomes  necessary. 

Fractures  of  bones  are  said  to  be  caused  sometimes  by  blows 
received  by  the  mother  before  labor.  Jardine  reports  a  case  of 
intra-uterine  fracture  of  the  skull. 

Fracture  of  the  skull  occasionally  occurs  during  delivery. 
When  the  bone  is  also  depressed,  causing  injury  to  the  brain  or 
haemorrhage,  the  condition  becomes  very  serious  and  frequently 
results  in  death.  When  there  are  symptoms  of  pressure,  elevate 
or  trephine  the  depressed  bone. 

Fracture  of  Long  Bones. — The  long  bones  which  are  most  fre- 
quently fractured  are  the  femur,  clavicle,  and  humerus.  Treat 
in  the  usual  way  by  the  application  of  plaster  or  splints. 

Injury  to  Muscles. — Haemorrhage  sometimes  occurs  in  the 
substance  of  muscles,  especially  the  sterno-cleido-mastoid,  caus- 
ing a  hard  lump  or  haematoma.  It  is  apt  to  occur  a  few  days 
after  birth  and  usually  disappears  in  a  few  weeks. 

Injury  to  the  Eyes. — In  high  or  mid-forceps  delivery  one  blade 
usually  presses  over  or  near  the  eye.  Generally  no  injury  results, 
but  occasionally  the  eye  is  more  or  less  hurt  or  even  destroyed. 
In  a  flat  pelvis  the  injury  to  the  eye  is  sometimes  caused  by  the 
promontory.  Sometimes  subconjunctival  haemorrhage  or  haem- 
orrhage into  the  back  of  the  orbit  occurs,  but  is  generally  soon 
absorbed.  Corneal  opacities  have  not  infrequently  occurred  in 
the  Glasgow  Maternity  Hospital.  Jardine  tells  us  that  in  most 
of  the  cases  the  opacity  cleared  up,  but  there  was  usually  a  linear 
scar  left  in  the  vertical  axis. 

Injury  to  Nerves. — Pressure  of  the  forceps  blade  frequently 
causes  injury  to  the  seventh  nerve,  resulting  in  facial  paralysis. 
Usually  improvement  commences  in  a  few  hours  and  the  paralysis 
disappears  in  a  few  days.     Injury  to  the  brachial  plexus  is  a  very 


DISEASES    OF    THE    NEW-BORN    CHILD  491 

rare  event,  but  cases  of  such  injury  throufi;h  dislocation  of  the 
head  of  the  humerus  are  reported.  Another  rare  form  of  paralysis 
of  the  arm,  affecting  chiefly  the  deltoid,  biceps,  and  supinator 
longus  muscles,  is  known  as  Duchenne's  paralysis. 

ABNORMALITIES  AND  DISEASES  OF  THE  NEW-BORN 

CHILD 

Imperforate  Anus. — As  before  stated,  one  should  always  con- 
sider the  possibility  of  imperforate  anus  when  examining  the 
new-born  child.  Sometimes  there  is  a  condition  akin  to  imper- 
forate anus,  of  complete  obstruction  of  the  bowel  one-half  inch 
above  the  anus.  If  the  bowels  do  not  move  within  a  few  hours 
after  birth,  examine  the  rectum  by  passing  up  the  little  finger. 

Treatment.  Operate  at  once.  Incise  and  carefully  dissect 
upward  until  the  blind  end  of  the  rectum  is  reached.  Dilate 
the  opening  thus  made,  daily,  with  a  bougie  to  prevent  con- 
traction. 

Umbilical  hernia  in  a  minor  degree  is  not  unusual.  It  should 
be  treated  by  the  application  of  a  simple  pad  made  of  a  penny  or 
a  piece  of  sheet  lead  properly  covered,  or  by  a  special  rubber  pad 
as  made  by  the  manufacturers,  kept  in  position  by  a  piece  of  ad- 
hesive plaster  or  an  abdominal  bandage. 

Umbilical  Haemorrhage. — Apart  from  haemorrhage  which  may 
occur  from  insufficient  ligation  or  slipping  of  the  ligature,  second- 
ary haemorrhage  occasionally  occurs  between  the  fifth  and  fifteenth 
day.     The  supposed  causes  are  syphilis  and  haemophilia. 

Treatment.  In  the  majority  of  cases  the  patient  dies  because 
the  haemorrhage  cannot  be  controlled.  Use  a  compress  of  lint 
saturated  with  a  styptic  tightly  applied  with  adhesive  strips;  or 
transfix  umbilicus  with  two  needles  placed  at  right  angles  and 
surround  tightly  with  a  figure-of-eight  ligature. 

Umbilical  vegetations  from  the  floor  of  the  umbilical  fossa 
sometimes  appear  after  the  falling  of  the  cord. 

Treatment.  Cauterize  with  solid  stick  of  nitrate  of  silver  and 
apply  a  dry  dressing  of  boric  acid. 

Engorgement  of  the  breasts  is  quite  common  in  infants,  and 
generally  appears  between  the  fourth  and  tenth  days  after 
birth.  A  milky  fluid  is  secreted  and  can  easily  be  squeezed 
out,  but  unfortunately  the  squeezing-out  process  is  fraught  with 


492  DEFOEMITIES    OF    THE    BONY    PELVIS 

danger  and  not  infrequently  causes  suppuration.  Without  such 
squeezing  suppuration  may  occur  from  septic  infection. 

Treatment.  Be  sure  to  warn  the  nurse  not  to  squeeze  the 
breasts.  Avoid  everything  that  is  hkely  to  irritate.  Do  not 
allow  even  rubbing  with  warm  oil,  as  frequently  recommended. 
Put  a  pledget  of  cotton  over  the  breast  under  the  binder  for  pro- 
tection.    When  suppuration  occurs  incise  freely  at  once. 

Jaundice  or  icterus  is  very  common  in  early  infant  life.  It 
generally  requires  no  treatment,  although  it  is  perhaps  well  to  give 
one  dose  of  castor  oil  or  a  half  grain  of  gray  powder  three  times  a 
day  for  six  doses.  Occasionally  a  severe  form  of  icterus  occurs, 
caused  by  or  accompanied  by  occlusion  of  the  bile  ducts  or  syph- 
ilitic disease  of  the  liver.     It  is  usually  fatal. 

Club  feet  should  be  carefully  looked  after  by  the  physician 
and  nurse.  The  nurse  when  instructed  by  the  doctor  can  do 
much  in  the  way  of  curing  the  deformity  by  straightening  the  foot 
and  massage  of  the  faulty  muscles  many  times  a  day.  A  simple 
medicated  oil,  such  as  a  weak  menthol  liniment,  a  dram  each 
of  chloroform  and  menthol  in  four  ounces  of  olive  oil,  may  be  used. 

Spina  bifida  is  really  a  spinal  meningocele  due  to  a  gap  in  the 
spine.  This  is  a  very  serious  condition,  and  should  be  treated  by 
a  skilled  surgeon. 

Ophthalmia  neonatorum  is  a  form  of  purulent  conjunctivitis 
most  frequently  caused  by  gonorrhoea.  The  symptoms  generally 
appear  on  the  second  or  third  day,  but  may  be  present  at  birth. 
When  the  symptoms  appear  five  days  or  more  after  birth,  they 
are  generally  due  to  infection  by  attendants.  The  inflammation 
is  very  virulent  and  frequently  causes  irreparable  damage. 

Symptoms.  The  eyelids  become  red,  and  swollen  with  a 
copious  secretion,  at  first  serous  but  soon  becoming  purulent.  If 
prompt  treatment  is  not  adopted  the  eyes  are  soon  destroyed. 

Prophylatic  Treatment.  Employ  antiseptic  vaginal  douches  in 
all  cases  in  which  the  patients  have  suspicious  discharges.  Drop 
two  or  three  minims  of  a  2  per  cent,  solution  of  nitrate  of  silver 
into  each  eye  of  the  babe  after  the  head  is  born.  Separate  the 
lids  before  putting  in  the  drops.  This  is  done  as  a  matter  of  rou- 
tine in  all  cases  in  the  Burnside  Hospital.  We  find  the  nitrate  of 
silver  (Crede)  more  satisfactory  than  a  solution  of  bichloride 
1  to  2,000,  or  a  solution  of  protargol,  20  per  cent.  In  private  prac- 
tice it  is  generally  sufficient  to  wash  out  the  eyes  with  a  solution 


DISEASES    OF    THE    NEW-BORN    CHILD  493 

of  boric  acid.  If,  however,  there  is  a  vaginal  discharge,  one  should 
always  use  one  of  the  strong  antiseptic  solutions. 

Curative  Treatment.  Obtain  the  assistance  of  a  skilled  oculist 
at  once  if  possible.  Wash  away  the  pus  with  a  saturated  solution 
of  boric  acid,  and  instil  a  couple  of  drops  of  a  solution  of  silver 
nitrate  every  two  hours. 

Cyanosis  is  generally  caused  by  some  malformation  of  the 
heart,  such  as  non-closure  of  the  foramen  ovale,  or  deficiency  in 
the  interventricular  septum  or  great  vessels,  such  as  the  pulmo- 
nary artery.  As  a  consequence  the  blood  is  deficient  in  oxygen 
and  has  an  excess  of  carbon  dioxide.  The  resulting  blueness  of 
the  skin  is  most  pronounced  over  the  cheek-bones,  nose,  lips,  and 
fingers.  The  action  of  the  heart  is  rapid  and  tumultuous;  various 
sorts  of  bruits  are  sometimes  heard;  the  respiration  is  disturbed; 
evidences  of  failure  of  nutrition  usually  soon  appear.  Most  babes 
thus  affected  die  within  a  few  months  after  birth.  They  may, 
however,  live  for  years,  but  always  show  signs  of  impaired  vitality. 
The  main  indication  as  to  treatment  is  to  keep  the  child  as  quiet 
as  possible. 

Tetanus  neonatorum  is  a  rare  disease  beginning  within  ten 
days  after  birth.  After  some  fretfulness  and  disinclination  to 
nurse,  rigidity  of  the  muscles  appears  and  reaches  its  maximum 
in  twelve  to  twenty-four  hours.  The  rigidity  generally  commences 
in  the  masseter  muscles ;  the  head  is  soon  thrown  back  with  per- 
haps opisthotonus,  while  there  is  general  flexion  of  the  extremities. 
It  is  a  specific  disease  due  to  the  invasion  of  the  tetanus  bacillus, 
the  seat  of  infection  being  most  frequently  the  umbilical  wound. 

Treatment.  Preventive  treatment  by  cleanly  management  of 
the  cord  is  the  most  important  consideration.  The  disease  when 
established  is  nearly  always  fatal.  The  best  medicines  are  chloral 
and  sulphonal  by  the  rectum,  one  to  two  grains  of  the  former 
every  hour;  three  or  four  grains  of  the  latter  every  two  hours; 
or  the  tetanus  antitoxin  as  produced  by  our  leading  manufacturing 
chemists. 

Discharge  of  blood  from  the  vagina  occasionally  occurs.  As 
a  rule,  it  is  not  at  all  serious  and  ceases  in  a  day  or  two. 

Syphilis. — The  infant  may  show  symptoms  of  syphilis  at  birth 
or  shortly  after  birth.  The  earlier  the  symptoms  appear  the 
worse  the  attack  will  be.  The  symptoms  are  the  ordinary  copper- 
colored  eruption,  bullae  especially  on  palms  of  hands  and  soles  of 


494  DEFOEMITIES    OF    THE    BONY    PELVIS 

feet,  coryza,  fissures  of  anus  and  mouth,  emaciation,  and  evidences 
of  visceral  and  bone  disease. 

Treatment.  Administration  of  mercury  by  the  mouth  or 
preferably  by  inunction. 

Er3rthema  intertrigo  is  a  hypersemic  disorder  occurring  between 
the  thighs  and  over  the  buttocks.  As  a  rule  there  is  no  infiltra- 
tion or  thickening,  and  thus  it  is  distinguished  from  eczema ;  but 
sometimes  it  grows  worse  and  becomes  an  actual  eczema.  It  is 
generally  due  to  want  of  care  in  changing  the  napkins  and  cleans- 
ing the  parts,  but  it  may  occur  under  the  most  careful  nursing. 

Treatment.  It  is  of  course  important  to  change  the  napkins 
as  soon  as  they  become  moist  and  cleanse  the  parts  thoroughly. 
Use  very  bland  soaps,  and  remember  that  too  much  water  often 
increases  the  irritation.  The  best  apphcations  are :  first,  dusting 
powders ;  second,  lotions ;  third,  ointments. 

The  best  powders  are  boric  acid,  talcum,  or  the  old-fashioned 
baked  flour.     The  following  mixture  answers  well: 

5    Pulveris  acidi  borici 3  j ; 

Pulveris  zinci  oxidi 3  j ; 

Pulveris  talci 3  v. 

One  of  the  best  lotions  is  a  saturated  solution  of  boric  acid.  One 
of  the  best  ointments  is  cold  cream. 

Tongue-tie  is  said  to  exist  when  the  frenum  is  too  short  or 
comes  too  far  forward.  It  occasionally  prevents  the  child 
from  sucking,  but  nothing  hke  so  frequently  as  is  supposed  by 
the  laity. 

Treatment.  Place  the  babe  with  its  head  on  the  nurse's  knees 
toward  the  surgeon.  Raise  the  tip  of  the  tongue,  put  the  frenum 
on  the  stretch  with  two  fingers  of  the  left  hand  and  cut  through 
its  thin  edge  with  a  sharp  pair  of  scissors,  pointing  the  scissors 
downward  parallel  to  the  ranine  veins.  Then  tear  the  frenum 
with  the  tip  of  the  nail  of  the  forefinger  of  either  hand  to  an  extent 
sufficient  to  allow  free  movement  of  the  tongue.  If  a  free  cut  is 
made  with  the  scissors  parallel  to  the  base  of  the  tongue,  dangerous 
haemorrhage  may  ensue. 

Thrush  or  sprue  is  the  common  name  of  a  parasitic  stomatitis, 
the  parasite  being  the  oidium  albicans  or  saccharomyces  albicans 
which  is  identical  with  the  mold  of  wine.  White  patches  appear 
in  many  parts  of  the  mouth,  including  the  tongue,  cheeks,  and 


DISEASES    OF    THE    NEW-BORN    CHILD  495 

hard  palate,  and  occasionally  the  soft  palate,  pharynx,  and  per- 
haps the  stomach  and  intestines. 

Treatment.  Strict  cleanliness  in  all  respects  will  prevent 
thrush.  When  the  patches  appear,  apply  the  glycerinum  acidi 
borici  or  a  solution  of  salicylic  acid  1  to  250  frequently.  The  solu- 
tion of  borax  and  honey  so  commonly  used  is  objectionable,  be- 
cause the  honey  tends  to  increase  the  growth  of  the  parasite. 
Indigestion  is  frequently  a  complication,  and  should  be  treated 
with  half-grain  doses  of  gray  powder  or  teaspoonful  doses  of 
castor  oil. 

Colic  is  one  of  the  most  frequent  ailments  of  infancy.  The 
most  common  cause  is  some  error  in  feeding.  The  most  common 
symptom  is  an  intermittent  and  loud  cry,  the  infant  drawing  up 
its  knees  during  the  paroxysm.  The  babe  sometimes  cries  because 
of  hunger,  but  such  a  cry  is  more  constant,  less  loud,  and  more 
like  fretting. 

Treatment.  Observe  great  care  as  to  food  and  regularity  in 
feeding.  Carminatives,  such  as  peppermint,  anise,  fennel,  gin, 
whisky,  etc.,  should  be  avoided.  Half  a  teaspoonful  of  glycerine 
to  an  ounce  of  warm  water  may  be  given,  or  as  much  of  this  mix- 
ture as  the  babe  cares  to  take.  A  high  enema  of  a  pint  of  warm 
water  through  a  double  rubber  cannula  or  an  ordinary  enema  of 
a  dessertspoonful  of  glycerine  in  three  ounces  of  hot  water  will 
sometimes  have  a  good  effect.  One  grain  of  chloral  hydrate  with 
ten  drops  of  glycerine  and  a  teaspoonful  of  warm  water  will  often 
afford  prompt  relief.  Half-grain  doses  of  gray  powder  three  times 
a  day  for  two  days,  or  a  single  teaspoonful  dose  of  castor  oil,  as 
recommended  for  thrush,  will  often  produce  good  results. 

Adherent  prepuce  and  phimosis. — Every  male  child  should  be 
carefully  examined  the  first  week  after  birth  to  ascertain  the 
condition  of  the  prepuce.  There  is  commonly  slight  adhesion,  and 
occasionally  contraction  or  phimosis. 

Treatment  of  adhesion.  "  Strip  "  the  glans  and  secure,  if  pos- 
sible, a  prepuce  freely  movable.  The  mother  or  nurse  should 
retract  the  prepuce  and  wash  the  parts  daily.  If  an  easily  glid- 
ing prepuce  cannot  be  obtained  on  account  of  phimosis,  some 
cutting  operation  such  as  circumcision  is  necessary.  Complete 
removal  of  the  foreskin,  however,  leaves  a  tender,  sensitive  glans 
exposed — a  condition  not  generally  desirable. 

33  . 


CHAPTER  XXIV 
OBSTETRICAL  OPERATIONS 

General  Considerations. — The  important  consideration  in  all 
kinds  of  obstetrical  procedures  is  cleanliness,  involving  as  it  does 
both  asepsis  and  antisepsis.  For  reasons  already  given  it  will  be 
considered  that  asepsis  alone  is  not  sufficient  for  obstetrical  opera- 
tions, because  the  parts  concerned  cannot  be  made  aseptic. 

During  childbirth  our  aim  is  to  have  the  patient  clean  in  every 
part  of  her  body.  She  gets  her  bath  and  lies  on  a  clean  bed.  In 
addition,  the  vulva  and  adjacent  parts  are  thoroughly  scrubbed 
with  soap  and  hot  water.  Nearly  all  soaps  are  more  or  less  anti- 
septic, but  green  soap,  which  is  the  best  for  such  purposes,  is 
strongly  so.  We  then  wash  with  our  antiseptic  solutions.  We 
consider  for  obstetrical  purposes  that  the  corrosive  sublimate 
solution  answers  admirably  for  this  external  cleansing,  and  that 
lysol  solutions  and  iodoform  gauze  are  better  suited  for  the  utero- 
vaginal canal;  or,  if  we  are  limited  to  one  antiseptic,  we  choose 
lysol  as  the  one  that  is  suitable  and  efficacious  in  all  sorts  of 
obstetrical  procedure. 

We  endeavor  to  have  our  hands,  instruments,  and  all  the  sur- 
roundings absolutely  clean.  Under  such  circumstances  we  dilate 
the  cervix,  apply  the  forceps,  perform  internal  version,  deliver 
the  placenta  manually,  etc.,  without  any  further  attempts  at 
asepsis  or  antisepsis.  At  this  point  we  differ  to  some  extent. 
Many  think  that  in  most  forceps  deliveries,  and  in  all  cases  where 
the  hand  has  been  introduced  into  the  uterus,  an  intra-uterine 
douche  is  advisable.  Others  think  that  such  an  intra-uterine 
douche  is  generally  harmful  to  some  extent,  and  that  it  is  unnec- 
essary if  a  clean  hand  has  been  used.  The  gynaecologist,  as  a  rule, 
will  not  perform  any  operation  on  the  vagina  or  uterus  without 
endeavoring  to  make  the  whole  field,  including  the  vagina,  abso- 
lutely free  from  organisms,  so  far  as  such  can  be  accomplished. 
There  is  a  certain  class  of  obstetrical  operations  in  which  the  rules 
of  the  gynaecologist  are  advisable.  It  may  be  well  to  refer  to 
496 


GENERAL    CONSIDERATIONS  497 

some  notes  of  warning  given  by  the  gyniecologists  which  are  of 
equal  importance  to  obstetricians  under  all  circumstances. 

The  nurse  may  inadvertently  convey  septic  matter  to  the 
patient.  One  should  neyer  consider  that  a  nurse  is  surgically 
clean  until  he  has  proved  her  to  be  so,  no  matter  through  what 
training  school  she  has  passed.  I  witnessed  a  very  important 
operation  not  long  since,  when  one  of  our  best  surgeons  did  his 
work  in  a  very  skilful  and  cleanly  way.  He  was  assisted  by  two 
surgeons  and  two  nurses,  I  being  simply  an  onlooker.  One  of  the 
nurses  happened  to  make  three  or  four  mistakes.  She  pushed  up 
her  left  sleeve  once  with  her  right  hand  when  it  was  not  surgically 
clean;  she  allowed  surgical  dressings  to  touch  the  same  sleeve 
twice;  she  touched  a  chair  at  another  time  after  she  had  carefully 
washed  her  hands  and  had  commenced  to  handle  the  dressings. 
Such  mistakes  are  not  small — they  are  wofully  and  terribly  large. 
The  patient  died  of  septicaemia.  I  cannot  say  that  the  nurse 
referred  to  (a  very  worthy  and  conscientious  woman)  was  respon- 
sible for  the  poisoning ;  but  I  know  the  operation  was  not  aseptic, 
while  the  surgeon-in-chief  thought  it  was. 

It  is  to  be  feared  that  both  general  surgeons  and  obstetricians 
still  make  many  mistakes  about  these  supposed  small  matters. 
They  know,  perhaps,  that  it  is  not  safe  to  take  a  needle  and  thread 
from  the  floor  and  use  them,  but  they  frequently  do  not  know 
how  to  sterilize  the  same  piece  of  thread.  In  some  cases  they 
think  that,  after  soaking  it  for  a  few  minutes  in  a  2  or  3  per  cent, 
solution  of  lysol,  or  a  couple  of  minutes  in  boiling  water,  it  will  be 
sterile.  Certain  germs,  and  especially  certain  spores,  will  not  be 
thus  destroyed. 

In  all  operations  involving  the  invasion  of  the  vagina  during 
pregnancy,  such  as  induction  of  abortion,  removal  of  blighted 
ovum,  curettement  in  inevitable  abortion,  induction  of  premature 
labor,  etc.,  it  is  better  to  prepare  the  vagina  as  for  a  vaginal  hys- 
terectomy. Such  preparation  is  probably  advisable,  even  though 
it  be  considered  that  in  the  great  majority  of  cases  the  vagina  is 
practically  sterile.  It  may  be  considered  sterile  in  a  sense  because 
it  contains  no  pathogenic  cocci,  and  therefore  nothing  which  can 
produce  septicaemia.  It  does,  however,  contain  bacteria,  which 
produce  putrefaction  under  certain  circumstances  (see  page  366). 
I  fear  these  bacteria  in  operative  work  before  and  after  labor, 
but  I  generally  disregard  them  during  labor. 


498  OBSTETEICAL    OPERATIONS 

Preparation  of  Patient. — For  any  operation  on  the  genital 
organs  during  pregnancy,  commence  to  prepare  the  patient  one 
or  two  days  before  the  operation.  It  is  better  to  have  the  prep- 
aration made  by  or  under  the  supervision  of  a  nurse.  On  the 
day  before  operating  give  her  a  purgative  before  breakfast,  and 
administer  an  enema  about  eight  or  nine  o'clock  in  the  evening. 
Give  her  a  bath  about  one  hour  after,  scrubbing  her  well,  using 
soap  and  fairly  hot  water.  Put  her  in  bed  and  as  soon  as  con- 
venient administer  a  vaginal  douche,  using  a  gallon  or  two  of 
fairly  hot  lysol  solution  1  per  cent.  On  the  morning  of  the  oper- 
ation administer  another  enema  of  warm  boric  solution  3  per  cent., 
three  or  four  hours  before  the  operation.  As  soon  after  this  as 
convenient,  shave  or  cut  closely  with  scissors  sufficient  hair  from 
the  labia  majora  and  mons  veneris  to  give  clear  space  for  opera- 
tion. Wash  the  pubic,  peritoneal,  and  anal  regions  and  the  inner 
surfaces  of  the  thighs  with  soap  (preferably  green  soap)  and  hot 
water,  and  finally  a  hot  solution  of  lysol  1  or  2  per  cent.  The 
nurse  may  then  apply  a  vulvar  pad  soaked  in  a  1  to  100  lysol 
solution  or  a  1  to  2,000  bichloride  solution.  When  the  operator 
arrives  he  should  first  prepare  himself,  arrange  his  instruments 
which  have  been  sterilized,  and  see  that  the  nurse  has  completed 
her  preparations.  Then  see  that  the  bladder  is  empty.  After 
the  bladder  is  emptied  rinse  the  hands  in  the  lysol  solution  which 
is  in  a  basin  close  at  hand.  Then  wash  vulva  and  adjacent  parts 
as  was  formerly  done  by  the  nurse.  Then  scrub  the  vagina  with 
green  soap  and  hot  water,  using  a  piece  of  absorbent  cotton  as  a 
mop.  Then  douche  thoroughly  with  lysol  solution.  The  patient 
is  now  prepared  for  the  operation. 

Sterilizing  of  Instruments. — Various  forms  of  sterilizing  cham- 
bers are  in  use,  some  of  which  are  very  good,  while  others  are  of 
doubtful  utility  and  difficult  to  manage.  Fortunately,  they  are 
not  required,  as  we  can  thoroughly  sterilize  our  instruments, 
appliances,  ligatures,  etc.,  by  keeping  them  in  boiling  water  for 
fifteen  minutes.  A  small  teaspoonful  of  common  salt  and  half  a 
teaspoonful  of  sodium  carbonate  should  be  added  to  each  pint  of 
water.  After  the  instruments  are  sterilized  they  should  be  placed 
in  a  1  per  cent,  solution  of  lysol  or  in  plain  sterilized  water. 

As  the  boiling  dulls  the  edges  of  sharp  instruments  and  the  points 
of  needles,  I  prefer  to  sterilize  knives,  scissors,  needles,  etc.,  by 
first  washing  in  soap  and  water  or  warm  lysol  solution,  then  im- 


GENERAL    OPERATIONS  499 

mcrsing  in  pure  lysol  for  five  minutes,  and  then  placing  them  in 
lysol  solution  1  per  cent,  or  sterile  water. 

GENERAL  OPERATIONS 

Sutures. — Most  of  the  wounds  caused  during  parturition  should 
be  sutured.  Asepsis  and  antisepsis  have  made  the  modern  suture 
absolutely  safe.  In  obstetrical  surgery,  silk,  silkworm  gut,  cat- 
gut, kangaroo  tendon,  and  silver  wire  are  used.  We  can  easily 
sterihze  our  silk,  silkworm  gut,  kangaroo  tendon,  and  silver  wire, 
but  it  is  more  difficult  to  sterilize  the  catgut.  It  is  better  to  have 
it  absolutely  sterile  and  at  the  same  time  sufficiently  antiseptic  to 
make  it  unfit  as  a  culture  medium  for  pathogenic  microbes.  The 
kangaroo  tendon  is  suitable  for  cases  in  which  the  catgut  is  used, 
and  some  say  safer,  because  the  tendon  can  be  easily  sterilized 
and  is  less  susceptible  to  infection  than  the  catgut.  The  silk  is 
tied  in  a  reef  knot  or  a  surgeon's  knot,  silkworm  gut  in  a  surgeon's 
knot,  kangaroo  tendon  in  a  reef  knot,  catgut  in  a  triple  reef  knot, 
silver  wire  is  twisted. 

Hypodermic  Injection. — This  small  operation  may  seem  insig- 
nificant, and  yet  it  is  sometimes  followed  by  serious  consequences. 
A  few  years  ago  one  of  our  students  had  serious  septicaemia  from 
the  use  of  a  hypodermic  syringe.  Senn  reports  a  very  distressing 
case.  The  father  of  a  young,  promising  physician  suffered  from 
a  painful  but  not  serious  affection.  The  son  made  a  hypodermic 
injection  of  morphine.  The  patient  died  in  a  few  days  from  acute 
sepsis,  which  had  its  starting-point  at  the  seat  of  puncture.  The 
needle  had  not  been  sterilized.  Hypodermic  needles  and  trocars 
should  always  be  sterilized  by  keeping  them  fifteen  minutes  in 
boiling  soda  solution.  Do  not  pass  them  through  a  flame  or  dip 
them  in  lysol  solution.  The  boiling  process  is  the  only  safe  pro- 
cedure. Thoroughly  cleanse  the  seat  of  puncture  before  intro- 
ducing the  needle.  This  can  be  done  with  soap  and  water ;  but  it 
is  safer  to  also  clean  the  skin  with  turpentine  or  lysol  solution. 

Subcutaneous  Injections  of  Salt  Solutions. — Add  a  teaspoonful 
each  of  common  salt  and  acetate  of  soda  to  a  pint  of  sterilized  water 
raised  to  a  temperature  of  100°  F.  Various  forms  of  apparatus 
have  been  invented,  but  the  simplest  way  is  to  use  an  aspirating 
needle  attached  to  a  rubber  tube  having  a  funnel  or  fountain  of 
some  sort  at  the  upper  end.    Clean  thoroughly  the  seat  of  puncture, 


500  OBSTETEICAL    OPEEATIONS 

as  before  described.  Make  a  small  incision  in  the  skin  with  a 
scalpel  and  push  in  the  needle  while  the  water  is  running  through 
it,  to  prevent  the  injection  of  air.  The  injections  are  most  com- 
monly made  behind  the  mammary  gland. 

High  Rectal  Enemata. — Add  a  teaspoonful  each  of  salt  and 
acetate  of  soda  to  a  pint  of  warm  water.  Use  a  fountain  syringe 
with  a  large  gum-elastic  catheter  as  a  nozzle.  Pass  the  catheter 
about  eight  or  nine  inches  up  the  bowel.  This  should  be  done 
very  gently,  as  the  sphincter  ani  is  frequently  very  irritable  and 
some  patients  object  seriously  to  the  procedure.  Most  people  can 
retain  12  to  16  ounces.     Absorption  as  a  rule  takes  place  quickly. 

Prolonged  irrigation  of  the  bowel  with  a  hot  salt  solution  (tem- 
perature 120°  F.)  is  sometimes  done,  as  already  mentioned.  For 
this  a  double-current  cannula  is  employed  and  several  gallons  of 
solution  are  used. 

Intravenous  Injection  of  Salt  Solution. — In  this  procedure  the 
saline  infusion  (common-salt-sodium-acetate  solution)  is  injected 
directly  into  the  vein.  The  apparatus  employed  may  be  the  same 
as  that  for  subcutaneous  injection,  a  small  cannula  taking  the 
place  of  the  needle.  Cleanse  the  skin  over  the  median  basilic  vein. 
Put  a  snug  bandage  round  the  arm  below  the  shoulder.  Make 
an  incision  one  inch  long  parallel  with  and  close  to  the  vein.  Free 
the  vein  from  its  attachment  for  half  an  inch  with  the  handle  of 
the  scalpel.  Introduce  beneath  the  vein  an  aneurism  needle 
threaded  with  a  double  silk  ligature.  Cut  the  ligature,  retain  both 
strands  in  position,  and  remove  the  needle.  Draw  one  of  the 
ligatures  into  the  lower  angle  of  the  wound  and  ligate  the  vein. 
Draw  the  other  ligature  into  the  upper  angle  of  the  wound  and  tie 
loosely  one-half  of  a  reef  knot.  Pick  up  the  vein  with  a  pair  of 
dissecting  forceps  and  make  an  oblique  upward  slit  with  scissors, 
taking  care  to  cut  through  the  entire  caliber  of  the  vein.  Pass 
the  cannula,  with  the  solution  running  through  it,  quickly  into  the 
vein.  Remove  the  bandage  from  the  arm.  Then  draw  tightly 
the  half  knot  round  the  vein  and  cannula.  Hold  the  funnel  or 
fountain  about  three  feet  above  the  vein  and  introduce  one  or  two 
pints  of  the  solution.  Then  withdraw  the  cannula,  tighten  the 
ligature  and  complete  the  reef  knot.  Cut  ends  of  both  ligatures 
close  to  the  knots.  Divide  the  vein  completely  between  the  lig- 
atures, close  the  skin  incision  by  two  or  three  sutures,  and  apply 
a  suitable  dressing. 


GENERAL    OPEKATIOXS  501 

Catheterization  is  always  dangerous,  because  it  may  cause  a 
troublesome  or  incurable  cystitis.  It  is  sometimes  a  very  difficult 
operation  to  perform  during  labor  and  after  labor.  During  labor 
the  difficulty  is  generally  .produced  by  the  pressure  of  the  present- 
ing part  on  the  urethra;  after  labor,  by  the  distortion  due  to 
bruising  and  tearing. 

Choice  of  Catheter.  A  soft-rubber  catheter  (Nos.  10  to  12, 
English)  is  generally  preferred.  It  is  not  easy  to  sterilize  such  an 
instrument.  If  it  becomes  septic,  or  if  there  is  reason  to  suspect 
that  it  has,  do  not  try.  Have  a  clean  new  rubber  catheter  in  the 
satchel.  Before  using  it  wash  it  with  soap  and  warm  water,  and 
leave  it  for  a  time  in  5  per  cent,  solution  of  lysol.  After  using  it 
wash  it  again  with  soap  and  water,  then  use  a  soda  solution,  and 
finally  leave  it  in  a  2  per  cent,  solution  of  lysol  or  a  1  to  2,000  solu- 
tion of  bichloride  until  wanted  again  for  the  same  patient.  When 
it  is  no  longer  required  for  this  patient,  destroy  it.  Never  use  a 
soft-rubber  or  a  gum-elastic  catheter  on  a  second  patient.  As  the 
parts  are  very  sensitive,  it  is  occasionally  advisable  to  administer 
an  anaesthetic.  I  saw  not  long  ago,  with  Dr.  Herbert  Hamilton,  a 
patient  who  had  retention  of  urine  after  labor.  Each  of  us  endeav- 
ored to  pass  a  soft-rubber  catheter  and  failed.  We  could  pass  it 
in  about  an  inch,  but  no  farther.  We  then  introduced  a  glass 
catheter  without  much  trouble.  It  is  well  to  carry  both  a  rubber 
and  a  glass  or  metallic  catheter  in  the  satchel.  The  patient  is 
placed  in  the  lithotomy  position  with  knees  widely  separated,  as 
this  puts  the  vestibule  on  a  stretch  and  generally  brings  the  meatus 
within  easy  reach.  Never  attempt  to  pass  a  catheter  after  labor 
by  the  sense  of  touch  under  the  clothing,  but  always  expose  the 
parts  thoroughly  in  the  best  possible  light.  The  legs  and  thighs 
should  at  the  same  time  be  covered  as  well  as  possible. 

Operation.  First  wash  external  parts.  Then  separate  the 
labia  with  two  fingers  of  the  left  hand,  so  as  to  bring  the  meatus 
into  view.  Cleanse  thoroughly  with  a  pledget  of  cotton  soaked  in 
warm  lysol  solution,  or  use  a  douche  with  same  solution.  Take 
the  clean  catheter  from  the  warm  solution,  pass  it  into  the  meatus 
and  gently  push  it  along  the  urethra  into  the  bladder.  When  dur- 
ing labor  the  presenting  part  is  wedged  low  down  in  the  pelvis, 
place  two  fingers  of  one  hand  on  this  head  or  breech,  as  the  case 
may  be,  and  push  it  up  out  of  the  pelvis  until  the  catheter  is 
passed  into  the  bladder  with  the  other  hand.     If  this  fails,  place 


502  OBSTETEICAL    OPEEATIONS 

the  patient  in  the  knee-chest  position,  which  will  cause  the  foetus 
to  gravitate  away  or  allow  it  to  be  pushed  away  from  the  pelvis, 
when  the  catheter  can  be  pushed  into  the  bladder. 

The  Douche. — Three  kinds  of  douche  are  recognized:  vulvar, 
vaginal,  and  uterine. 

Vulvar  Douche.  The  patient  is  placed  on  her  back  as  described 
for  catheterization.  Bring  nates  to  or  slightly  beyond  the  edge 
of  bed.  Place  under  the  buttocks  a  Kelly  pad  or  a  piece  of  mack- 
intosh or  oilcloth  so  arranged  that  the  water  as  it  runs  away  will 
be  carried  to  a  slop-pail  under  the  edge  of  the  bed.  Use  an  ordi- 
nary vulcanite  or  glass  nozzle  on  the  end  of  a  tube  running  from  a 
fountain.  Turn  the  stream  first  on  external  part  of  vulva  and 
adjacent  parts.  Then  separate  the  vulva  with  two  fingers  and 
direct  the  stream  to  parts  between  them. 

Vaginal  Douche.  In  all  cases  the  vulvar  should  precede  the 
vaginal  douche.  The  nozzle  and  its  openings  should  be  sufficiently 
large  to  allow  a  good  flow.  A  double  catheter — i.  e.,  one  with  one 
tube  for  the  in  and  the  other  for  the  outflow — is  not  necessary. 
Most  of  these  found  on  the  market  are  too  small  for  good  work. 
The  best  kind  of  nozzle  is  made  of  glass,  but  it  is  so  easily  broken 
that  many  prefer  one  made  of  vulcanite.  The  only  objection  to 
the  latter  is  that  boiling  water  soon  spoils  it.  A  metallic  nozzle 
is  suitable  in  many  cases,  but  not  for  a  very  hot  douche,  because 
the  metal,  being  a  good  conductor  of  heat,  becomes  hotter  than  the 
patient  can  bear.  The  openings  in  the  nozzle,  should  be  slits,  not 
round  holes,  and  situated  at  the  sides,  never  at  the  end.  A  nozzle 
with  a  hole  in  the  end  is  more  convenient  for  douching  the  external 
part  of  the  vulva  and  adjacent  parts,  but  one  prefers  as  a  rule  to 
complete  the  procedure  without  changing  nozzles.  For  purely 
external  douching  the  nozzle  with  the  shts  at  the  sides  may  require 
to  be  turned  sidewise,  or  the  solution  may  be  poured  over  the  vulva 
from  an  ordinary  pitcher.  After  this,  separate  the  labia  as  before 
described,  place  the  end  of  the  nozzle  just  within  the  vagina,  and 
the  flow  from  the  side  slits  will  accomplish  what  we  want. 

The  patient  has  been  placed  in  proper  position  for  the  vulvar 
douche.  Keep  her  in  the  same  position  and  introduce  the  nozzle 
well  into  the  vagina.  While  doing  so  also  introduce  two  fingers  into 
the  vagina  and  separate  so  as  to  insure  a  good  outflow.  Or  the 
two  fingers  may  be  first  passed  into  the  vagina,  then  separated,  and 
nozzle  passed  between  them. 


•     GENERAL    OPERATIONS  503 

Uterine  Douche.  It  has  boon  stated  that  an  intra-uterinc 
douche,  no  matter  how  carefully  administered,  is  frequently  fol- 
lowed by  serious  results;  and  one  can  readily  understand  that 
when  carelessly  administered  it  is  likely  to  be  followed  by  still 
more  serious  results.  Two  points  in  connection  with  the  intra- 
uterine douche  should  ever  be  kept  in  view:  (1)  unskilful,  and 
even  skilful,  administration  is  frequently  dangerous;  (2)  when 
skilful  administration  is  not  dangerous  it  is  frequently  useless. 
The  dangers  are  supposed  to  arise  from  shock,  forcing  fluid  or 
air  through  the  Fallopian  tubes  into  the  peritoneal  cavity,  dis- 
lodgment  of  clots  from  the  placental  site  causing  haemorrhage, 
allowing  the  entrance  of  fluid  or  air  into  the  sinuses,  or  poisoning 
from  the  absorption  of  the  antiseptic,  especially  when  corrosive 
sublimate  is  used.  Shock  was  the  apparent  cause  in  most  of  the 
cases  that  I  have  observed.  Why  shock  should  be  caused  by  the 
introduction  of  hot  water  into  the  uterine  cavity,  when  a  free 
outflow  is  allowed,  I  do  not  know.  Intra-uterine  injections  of  hot 
water  soon  after  labor,  as  for  post-partum  haemorrhage,  appear  to 
cause  less  serious  results  than  those  administered  some  days  after 
labor,  as  for  septicaemia.  I  have  had  no  experience  of  a  case  where 
death  has  been  caused  by  air  embolism  induced  by  a  douche. 
Such  cases,  however,  have  been  reported. 

Operation.  Both  the  vulvar  and  the  vaginal  should  precede 
the  intra-uterine  douche.  '  Introduce  the  large-sized  nozzle  such 
as  has  been  described,  and  endeavor  to  pass  it  up  to  the  fundus. 
In  order  to  do  this  the  nozzle  should  be  long  and  have  a  pelvic 
curve.  It  is  also  especially  important  that  the  tube  should  be 
large  enough  to  allow  a  full-sized  stream  to  pass  through.  In 
order  to  pass  the  nozzle  with  certainty  up  to  the  fundus  of  the  ante- 
flexed  uterus  it  is  necessary  to  employ  some  means  to  straighten 
the  uterine  canal  and  bring  its  axis  more  in  line  with  the  vagina, 
as  pointed  out  by  Chalmers  Cameron.  To  accomplish  it,  seize 
the  anterior  lip  of  the  cervix  with  a  pair  of  blunt  bullet  forceps 
and  draw  it  gently  downward.  Be  sure  that  the  water  is  passing 
through  the  tube  before  the  nozzle  is  passed  into  the  uterus. 
Let  the  assistant  pull  on  the  handle  of  the  bullet  forceps  while 
the  operator  places  one  hand  like  a  cap  over  the  fundus  and 
occasionally  presses  on  the  uterus  through  the  abdominal  wall 
so  as  to  expel  all  fluids,  clots,  and  debris  of  every  kind.  The 
slight   traction  on  the    anterior  lip  generally  keeps  the    cervix 


504  OBSTETEICAL    OPERATIONS 

sufficiently  open,  and  should  be  continued  after  the  nozzle  is 
withdrawn  until  all  the  fluids  and  debris  are  pressed  out  of  the 
uterine  cavity  by  the  hand  over  the  fundus.  If  corrosive  subli- 
mate has  been  used,  some  plain  hot  water  should  always  be 
injected  to  wash  out  or  dilute  any  of  the  solution  that  may  be 
retained  in  either  the  vagina  or  uterus  after  vaginal  or  uterine 
douches.  One  should  keep  in  view  the  fact  that  some  patients 
are  very  susceptible  to  its  evil  effects,  and  also  keep  in  mind  the 
ordinary  symptoms  of  mercurial  poisoning.  They  are  diarrhoea 
with  tenesmus,  and  occasionally  blood  and  mucus  in  the  stools, 
abdominal  pains,  sore  gums,  loosening  of  teeth,  salivation,  metallic 
taste,  occasionally  vomiting. 

Curettage. — The  use  of  any  metallic  curette  is  seldom  advis- 
able in  obstetrical  practice.  In  severe  cases  of  septicaemia,  espe- 
cially in  streptococcic  infection,  it  should  never  be  used,  for  reasons 
which  have  already  been  given.  It  may  be  used  occasionally 
with  advantage  for  inevitable  abortion  during  the  first  ten  weeks 
of  pregnancy.  It  may  also  be  used  occasionally  for  that  form 
of  haemorrhage  which  continues  for  a  long  time  after  labor,  due  to 
subinvolution  or  for  secondary  post-partum  haemorrhage,  as  before 
mentioned. 

Curettage  for  Early  Incomplete  Abortion.  Prepare  the  patient 
by  cleansing  vulva  and  vagina.  If  cervix  is  not  sufficiently 
dilated,  introduce  if  possible  a  cervical  and  vaginal  tampon,  or 
dilate  with  a  suitable  dilator.  The  ordinary  tents  are  more  or 
less  dangerous.  The  best  position  for  the  patient  is  on  the  side 
(Sims),  especially  when  vaginal  tamponage  is  done,  or  on  the  back, 
especially  when  a  dilator  is  used  for  the  cervical  canal.  If  the 
finger  cannot  be  introduced  into  the  uterine  cavity,  seize  the 
anterior  lip  of  the  cervix  with  volsella  or  bullet  forceps,  draw  it 
down  gently.  Let  an  assistant  seize  the  handle  of  the  forceps  and 
make  steady  traction,  while  the  dull  curette  is  passed  into  the 
uterus  with  one  hand  and  the  other  hand  is  placed  over  the  fundus 
so  as  to  ascertain  when  the  instrument  has  reached  the  top  of  the 
uterine  cavity.  When  this  has  been  accomplished  the  forceps 
may  be  held  in  one  hand,  while  the  curette  is  used  with  the  other. 
Scrape  the  interior  of  the  uterus  methodically;  first,  the  anterior 
surface ;  second,  the  left  side ;  third,  the  posterior  surface ;  fourth, 
the  right  side;  fifth,  the  right  cornu;  sixth,  the  left  cornu.  In 
curetting,   always  push  upward  gently   (Diihrssen),   but   scrape 


GENERAL    OPERATIONS  505 

downward  with  a  certain  amount  of  force.  One  is  more  apt  to 
perforate  the  uterine  wall  in  pushing  upward  than  in  scraping 
downward.  Such  perforation  with  a  clean  instrument  does  no 
great  damage  in  the  majority  of  instances,  but  its  occurrence  is  a 
very  serious  matter  when  curetting  for  incomplete  abortion  with 
septicicmia  or  sapra3mia.  It  is  certainly  an  unpleasant  accident 
in  any  case.  If  the  instrument  suddenly  passes  into  something 
like  empty  space,  it  may  be  a  question  whether  the  uterine  wall  has 
been  perforated  or  the  instrument  has  been  pushed  into  one  of  the 
Fallopian  tubes.  Generally,  however,  the  uterine  wall  has  been 
perforated.  After  scraping,  give  an  intra-uterine  douche  of  hot 
salt  solution,  using  a  double  cannula  or  some  form  of  nozzle  which 
will  insure  ample  return  flow.  Anaesthesia  is  generally  advisable 
but  not  always  necessary  for  this  operation.  If  a  metallic  instru- 
ment is  considered  necessary  a  dull  curette  with  a  somewhat 
flexible  stem  should  be  used.  I  know  of  none  better  than  Thom- 
as's dull  wire  curette,  which  consists  practically  of  a  copper  wire 
with  a  small  loop  at  its  extremity. 

Materials  for  vaginal,  cervical,  and  uterine  tampons  are  strips 
of  iodoform  gauze,  iodoform  cotton,  iodoform  linen  (more  correctly, 
iodoformed),  or  strips  lysoled,  borated,  or  carbonated — all  being 
previously  sterilized.  Pledgets  or  balls  of  absorbent  cotton  or  wool 
properly  medicated  may  also  be  used.  DUhrssen  frequently  uses  a 
combination  of  iodoform  gauze  and  salicylic  wool  for  one  tampon- 
ade. One  long  strip  is  better  than  a  number  of  separate  pledg- 
ets or  balls,  because  the  one  strip  can  be  removed  more  easily  and 
the  removal  causes  less  pain.  One  has  only  to  seize  the  end  of  the 
strip  and  pull  it  out  slowly,  while  with  a  large  number  of  pledgets 
one  has  to  search  for  them  and  remove  them  separately.  The 
latter  objection  may  be  removed,  however,  by  attaching  them 
to  a  single  string  about  six  inches  apart,  forming  the  so-called 
kite-tail. 

Tamponade. — The  use  of  the  tampon  has  been  frequently 
referred  to  in  other  chapters.  The  chief  varieties  of  tamponades 
are  vulvar,  vaginal,  cervical,  and  uterine. 

The  vulvar  tampon  or  the  vulvar  pad  is  used  to  control  haem- 
orrhage from  the  vulva,  especially  that  due  to  ruptured  labial 
thrombus  or  varix.  When  clots  are  present,  remove  them ;  if  there 
is  a  cavity,  pack  it  with  iodoform  gauze ;  if  necessary,  tamponade 
the  vagina  as  well;  put  a  pad  over  vulva,  hold  in  position  by  a 


506  OBSTETKICAL    OPEEATIONS 

T-bandage  tightly  applied.  This  T-bandage  is  applied  by  passing 
a  fairly  broad  bandage  (about  three  inches)  around  the  waist  and 
fastening  the  ends  in  front.  Another  piece  of  bandage  stitched 
to  the  center  behind  is  brought  forward  between  the  thighs  over 
the  vulva  pad  and  fastened  to  the  waist  bandage  in  front  of  the 
pubes. 

Vaginal  Tamponade.  Prepare  the  parts.  See  that  the  bladder 
and  rectum  are  empty.  Place  patient  in  Sims's  position.  The 
upper  half  of  the  vagina  should  be  ballooned  as  much  as  possible, 
in  order  to  enable  one  to  introduce  enough  material  to  properly 
control  haemorrhage  or  cause  dilatation  of  cervix,  or  both.  The 
dorsal  position  is  quite  suitable  for  uterine  curettage,  or  even  for 
uterine  tamponade,  but  never  for  efficient  vaginal  tamponade. 
Introduce  a  Sims's  speculum,  and  let  an  assistant  hold  it  in  posi- 
tion in  such  a  way  as  to  pull  back  the  perinseum  and  the  posterior 
vaginal  wall.  A  valvular  speculum  may  be  used,  but  nothing 
answers  so  well  as  a  Sims's,  especially  when  there  is  an  assistant. 
One  can  manage  by  using  one  or  two  fingers  to  retract  the  peri- 
nseum, as  recommended  by  Shauta;  or  an  imitation  of  Sims's 
speculum  may  be  improvised  by  bending  the  handle  of  a  dessert- 
spoon to  a  right  angle  close  to  the  spoon. 

Take  the  end  of  the  strip  in  a  dressing  forceps  and  first  pack  the 
posterior  vaginal  vault,  then  left  of  cervix,  then  anterior  vaginal 
vault,  then  right  of  cervix,  then  against  os.  Continue  to  pack  as 
tightly  as  possible  until  about  two-thirds  of  the  vagina  has  been 
filled.  A  dilated  or  ballooned  vagina  is  like  an  inverted  funnel, 
and  one  should  endeavor  to  fill  the  cone  but  not  the  pipe  or  mouth 
of  the  funnel.  The  entrance  to  the  vagina  is  like  the  short  pipe 
of  the  funnel  and  should  not  be  tightly  packed  so  as  to  put  it  on 
the  stretch,  because  this  causes  great  pain  and  frequently  retention 
of  urine.  If  the  very  dilatable  vault  is  properly  packed  it  is  seldom, 
perhaps  never,  necessary  to  pack  the  entrance.  It  is  better  to 
have  the  material  moistened  by  antiseptic  solution,  preferably 
lysol,  especially  the  first  half  of  the  tampon.  This  is  particularly 
important  when  using  iodoform  gauze,  because  it  makes  more  cer- 
tain the  antiseptic  action  of  the  iodoform,  which  is  inert  if  perfectly 
dry.  The  wet  strip  or  pledgets  can  also  be  packed  more  firmly 
than  the  dry  material.  The  soapy  lysol  also  tends  to  prevent 
irritation  of  the  vagina  and  make  the  tampon  more  easy  to  remove. 
The  simplest  plan  is  to  have  the  long  strip  or  kite-tail  in  a  bottle 


GENERAL    OPERATIONS  507 

with  a  proper  cover.  Let  an  assistant  remove  the  cover  and 
hold  the  bottle  while  the  end  of  the  strip  or  kite-tail  is  seized 
with  the  forceps  and  passed  directly  into  the  vagina.  It  is  con- 
venient to  moisten  the  strip  by  pulling  a  few  feet  out  of  the  bottle 
and  placing  the  portion  removed  in  a  basin  containing  a  1  per 
cent,  warm  lysol  solution.  Then  remove  from  basin,  squeeze 
well,  and  place  on  sterile  towel  close  to  patient's  nates.  Then 
introduce  the  strip  thus  moistened  into  the  vagina. 

An  iodoform  tampon  may  be  left  in  the  vagina  from  one  to 
two  days,  or  more  if  necessary ;  a  lysol  tampon  twenty  to  twenty- 
four  hours;  an  aseptic  tampon  eight  to  ten  hours.  An  iodoform 
tampon  which  has  been  also  lysoled  will,  as  a  rule,  cause  little  or 
no  irritation.  After  removal  a  second  may  be  introduced  at  once 
if  advisable.  A  third  and  a  fourth  may  be  introduced  without 
causing  much  irritation  or  any  septic  infection. 

Intra-uterine  Tavi'ponade.  Place  patient  in  the  cross-bed  posi- 
tion on  her  back.  See  that  the  bladder  and  rectum  are  empty, 
and  remove  all  clots,  membranes,  etc.,  from  cavity  of  the  uterus. 
Seize  anterior  and  posterior  lips  of  the  cervix  with  two  volsellae 
and  draw  the  os  uteri  down,  to  the  vulva  or  as  near  it  as  possible. 
Let  an  assistant  hold  the  handles  of  the  volsellse.  Introduce  the 
strip  of  iodoform  gauze  directly  from  the  bottle  (as  described  for 
vaginal  tampon)  into  the  uterine  cavity  with  a  long  dressing  for- 
ceps or  some  form  of  gauze  packer.  Place  one. hand  over  the 
uterus  to  ascertain  when  the  fundus  has  been  reached.  Gradually 
fill  the  uterus  tightly  from  fundus  downward.  Sometimes  the 
volsella  may  be  dispensed  with  if  the  uterus  is  carefully  pressed 
into  the  pelvis  by  an  assistant  with  hand  over  fundus.  Or  the 
whole  hand  may  be  passed  into  the  uterus  and  the  gauze  pulled  in 
and  packed  by  it.  After  the  cavity  has  been  filled  remove  the 
volsella  (if  used)  and  loosely  pack  the  vagina  with  the  gauze  while 
the  patient  is  still  on  her  back.  When  it  is  considered  necessary 
to  tampon  the  vagina  tightly,  turn  the  patient  and  place  her 
in  Sims's  position;  or  the  whole  utero-vaginal  tamponade  may  be 
done  with  the  patient  in  the  Sims's  position.  Remember  the 
objection  to  the  gauze  on  account  of  its  penetrability,  and  for 
severe  haemorrhages  use  the  medicated  cotton  wool  plugs,  espe- 
cially in  the  vagina.  If  the  bleeding  still  continues,  notwithstand- 
ing combined  gauze  and  wool  tamponade,  on  account  of  atony  of 
the  uterine  wall,  compress  the  uterus  from  without  against  the 


508  OBSTETRICAL    OPERATIONS 

tampon.  Sometimes  the  tampon  stops  the  haemorrhage  for  a 
time,  but  after  the  occurrence  of  strong  uterine  contractions 
bleeding  commences  afresh.  In  such  cases  the  blood  is  usually 
being  squeezed  through  the  plug,  and  the  latter  should  be  at  once 
removed. 

Episiotomy. — It  is  thought  that  one  or  two  clean  incisions 
may  prevent  rupture  of  the  perinaeum.  Make  each  cut  back- 
ward and  outward  from  the  side  of  the  fourchette  toward  the 
tuber  ischii.  After  delivery  suture  the  cuts.  I  know  of  no  prom- 
inent obstetrician  in  Great  Britain  or  America  who  approves  of 
episiotomy. 

Repair  of  Lacerations  of  the  Genital  Canal. — We  have  learned, 
chiefly  from  obstetricians  of  the  United  States,  the  vast  importance 
of  the  pelvic  floor  from  an  obstetrical  point  of  view.  We  now 
know  that  the  perinaeum — i.  e.,  the  triangular  body  situated  be- 
tween the  vagina  and  the  rectum — is  a  structure  of  but  little  im- 
portance when  compared  with  the  pelvic  floor.  The  student  learns 
in  the  dissecting-room  that  this  pelvic  floor  is  composed  chiefly 
of  muscle  and  fascia,  so  arranged  as  to  give  the  structure  consid- 
erable sphincteric  and  great  supporting  power.  It  is  probable  that 
the  principal  supporting  power  is  furnished  by  the  different  layers 
of  fascia.  We  should,  however,  consider  that  all  structures,  includ- 
ing both  muscles  and  fascia,  are  of  the  greatest  importance,  and 
when  torn  should  be  restored  as  nearly  as  possible  to  their  original 
relations  and  conditions. 

Commencing  from  above  and  going  downward,  the  most  serious 
injuries  are  lacerations  of  the  body  of  the  uterus  (generally  the 
lower  segment),  cervix,  vagina,  pelvic  floor,  perinaeum,  and  various 
parts  of  the  vulva.  It  is  the  duty  of  the  obstetrician  to  consider 
carefully  and  treat  properly  all  such  lacerations.  There  is  another 
class  of  injuries  which  the  obstetrician  should  ever  bear  in  mind — 
necroses  and  sloughs  of  tissues,  generally  produced  by  long-con- 
tinued pressure  of  the  presenting  part  of  the  child,  resulting  in 
various  forms  of  fistulae.  He  should  endeavor  to  prevent  such 
accidents,  and  thus  avoid  the  humiliation  of  giving  his  patient  into 
the  hands  of  the  gynaecologists  for  after-treatment. 

Lacerations  of  the  Cervix. — Obstetricians  have  differed  much 
in  the  past  as  to  the  proper  treatment  of  lacerations  of  the  cervix. 
It  is  now,  however,  generally  believed  that  in  the  great  majority 
of  cases  such  lacerations  should  be  left  alone.     Nature  can  care 


GENERAL    OPERATIONS  509 

for  the  ordinary  small  lacerations  better,  as  a  rule,  than  the 
obstetrician.  If  there  is  considerable  tearing  of  the  vagina  or 
copious  haemorrhage  with  contracted  uterus,  one  should  suspect 
serious  laceration  of  the  cervix  and  ascertain  the  condition  by 
vaginal  examination,  using  a  speculum  if  necessary.  When  a 
deep  laceration  is  found  the  primary  suture  is  advisable. 

Operation.  Immediate  operation  should  be  performed  when 
the  indication  is  to  stop  haemorrhage.  An  anaesthetic  is  generally 
unnecessary,  as  the  cervix  is  not  sensitive.  Place  patient  on  back 
in  the  cross-bed  position  with  nates  well  over  edge  of  bed.  Wash 
vulva  and  adjacent  parts,  but  do  not  administer  a  vaginal  douche. 
Retract  perinaeum  with  a  large  Sims's  speculum  or  a  Garrigues's 
weight  speculum.  Keep  the  anterior  wall  of  the  vagina  out  of 
the  way  with  a  retractor  if  necessary.  Pull  down  the  cervix  with 
a  single  volsella;  hold  the  two  lips  of  the  wound  in  contact  with 
the  volsella,  one  point  being  in  each  lip  near  the  lower  end  of  the 
tear.  Introduce  the  first  suture  on  a  level  with  or  just  above  the 
upper  angle  of  the  tear  and  tie  at  once.  This  should  control  the 
bleeding.  Then  introduce  one,  two,  or  three  more  sutures  if 
required.  Kangaroo  tendon  or  catgut  is  the  best  suture  for  this 
operation.  It  holds  sufficiently  long  to  allow  union,  and  it  pleases 
the  patient  much  to  be  told  that  no  stitches  will  require  removal. 
The  catgut  should  be  taken  with  a  clean  pair  of  forceps  from  the 
bottle  in  which  it  is  kept  in  alcohol  and  placed  on  a  sterile  towel  or 
plate,  because  if  placed  in  a  lysol  solution  or  in  sterilized  water  it 
will  swell  to  such  an  extent  that  it  cannot  be  threaded  in  an  ordi- 
nary needle.  It  is  also  convenient  to  place  the  kangaroo  tendon 
on  a  sterile  towel,  but  its  retention  for  a  limited  time  in  a  sterile 
or  antiseptic  solution  will  not  cause  swelling. 

Lacerations  of  the  Vagina. — There  may  be  lacerations  of  the 
vagina,  especially  in  the  upper  part,  which  do  not  involve  the 
pelvic  floor.  Such  a  laceration  is  frequently  continuous  with 
the  tear  of  the  cervix.  This  should  be  sutured  immediately 
after  the  repair  of  the  cervical  laceration.  Generally  it  is  more 
convenient  to  use  rather  short  needles  well  curved.  A  Hagedorn 
needle  is  suitable,  but  the  ordinary  curved  needle  held  in  a  needle- 
holder  is  satisfactory. 


510 


OBSTETRICAL    OPEEATIONS 


LACERATIONS  OF  THE  PELVIC  FLOOR  AND  PERINEUM 

Either  of  these  structures  may  be  injured  without  the  other, 
but  in  serious  tears  both  are  generally  involved.  As  a  matter 
of  convenience  we  may  consider  four  varieties:   (1)  Laceration  of 

the  pelvic  floor  and  four- 
chette ;  (2)  laceration 
of  the  perineal  body; 
(3)  laceration  of  the 
pelvic  floor  and  perineal 
body,  but  not  including 
the  sphincter  ani;  (4) 
laceration  of  the  pelvic 
floor  and  the  perineal 
body  extending  into  the 
rectum.  It  is  stated 
that  lacerations  of  the 
pelvic  floor  occur  in  35 
per  cent,  of  first  and  10 
per  cent,  of  subsequent 
labors.  I  think  those 
who  use  the  axis-trac- 
tion forceps  with  care 
have  a  smaller  propor- 
tion. 

When  should  the  op- 
eration be  performed  ? 
When  I  first  took  charge 
of  the  Burnside  Lying-in  Hospital  it  was  supposed  that  any- 
body could  ''stitch  a  torn  perinseum,"  and  the  members  of  the 
intern  staff  were  in  the  habit  of  performing  immediate  opera- 
tion, suturing  the  perineal  tear  without  any  regard  to  lacerations 
of  the  pelvic  floor,  and  at  the  same  time  being  careless  in  some 
cases  as  to  asepsis  or  antisepsis.  One  patient  thus  treated  died 
from  puerperal  sepsis.  Orders  were  then  issued  that  no  such 
operation  was  to  be  performed  excepting  by  or  under  the  direction 
of  a  member  of  the  visiting  staff.  We  found  that  the  patient  might 
be  left  a  considerable  time  after  the  completion  of  labor  before  oper- 
ation was  necessary,  although  we  seldom  waited  more  than  twenty- 
four  hours.     In  1894  a  patient   had  extensive  laceration  of  the 


Fig. 


168.  —  Lakgk    Tjlak    UN    RioHT    Side    of 
Pelvic  Floor. 


Showing  triangular  raw  surface  from  slight  tear 
involving  only  mucous  membrane  running  to 
left,  also  slight  tear  of  skin  and  body  of  peri- 
nseum.     (Burnside  Lying-in  Hospital.) 


LACEEATIOXS  OF  THE  TELVIC  FLOOR 


511 


perineal  body,  which  was  sutured  shortly  after  labor.  We  sus- 
pected non-union,  and  our  suspicions  were  correct,  as  we  found 
on  removal  of  sutures  in  eight  days.  On  the  tenth  day  we  found 
two  clean  granulating  surfaces.  Sutures  were  again  introduced 
by  Dr.  Field,  house  surgeon,  without  freshening  the  wound  sur- 
faces, and  good  union  resulted.  It  is  better,  however,  to  vivify 
granulation  surfaces  by  scraping  gently  with  the  sharp  edge  of  a 
scalpel  drawn  sidewise,  or,  some  say,  by  rubbing  them  with  a  fold 
of  cheese  cloth.  I  have  found  that  after  serious  lacerations  one 
is  likely  to  do  better  work  by  waiting  until  he  can  get  good  light 
and  make  full  preparations.  Immediately  after  labor  patients 
who  h;n'e  severe  lacerations  are  usually  exhausted  and  not  in  good 
condition  to  be  anaesthetized.     The  obstetrician  has  many  things 


Fig.  169. — Large  Bilateral  Tear  of  Pelvic  Floor,  Running  up  Each  Side 
OF  Median  Raphe  and  Slight  Tear  of  the  Perineal  Body. 

(Burnside  Lying-in  HospitaL) 


to  think  about  in  connection  with  the  care  of  the  babe  and  the 
mother,  who  has  probably  more  or  less  inertia  uteri.  Under  such 
circumstances  even  a  competent  and  careful  operator  can  scarcely 
do  his  best  work.  It  is  much  better  to  wait  one,  two,  or  three 
days,  when  thorough  and  careful  work  can  be  done. 

I  happened  to  be  asked  to  give  an  opinion  on  a  case  interesting 
3i 


512 


OBSTETEICAL    OPEEATIONS 


from  a  medico-legal  standpoint.  Dr.  A.  attended  Mrs.  B.  in  a 
very  difficult  and  prolonged  labor.  There  was  extensive  lacera- 
tion of  the  perineal  body  extending  to  the  rectum,  and  two  tears 

running  up  the  vagina 
as  far  as  the  Doctor 
could  see.  The  patient 
was  exhausted.  On  the 
following  day  Dr.  C.  was 
called  in  consultation 
and  performed  a  very 
difficult  and  tedious 
operation,  more  than 
thirty  sutures  being  re- 
quired. The  result  was 
good,  the  parts  were  re- 
stored and  healing  by 
first  intention  took 
place.  Dr.  C.  rendered 
a  separate  account  for 
the  operation.  Mr.  B. 
objected,  because  he  had 
been  told  that  it  was 
the  duty  of  the  obstet- 
rician to  "stitch"  such 
tears  immediately  after 
labor,  and  not  to  wait 
until  the  next  day  and 
have  a  separate  operation  with  an  additional  fee.  I  of  course 
expressed  the  opinion  that  Dr.  A.  was  right  in  every  respect, 
and  I  think  Mrs.  B.  was  extremely  fortunate  in  passing  into 
such  good  hands. 

I  recently  attended  a  slight,  small  woman  in  labor.  The  pel- 
vic measurements  were  nearly  normal.  Labor  somewhat  slow, 
but  fairly  satisfactory  until  the  end  of  the  first  stage — first  vertex 
position  favorable  in  all  respects.  Axis-traction  forceps  easily 
applied.  Slow,  easy  extraction.  While  the  head  was  coming 
through  the  vulva  I  noticed  shght  laceration  of  the  perineal  body, 
just  sufficient  to  require  one  or  two  sutures.  I  found  one  tear 
extending  upward  along  left  posterior  wall  of  the  vagina.  I  did 
not  know  how  far,  but  I  thought  only  a  short  distance.     The 


Fig.  170. — Sutures  Introduced  into  the 
Tears  of  the  Pelvic  Floor  without  Re- 
gard TO  the  Perineal  Body. 


LACEEATIONS    OF    THE    TELVIC    FLOOIi 


513 


patient  was  exhausted,  and  there  was  a  shght  post-partum  hajm- 
orrhage  requiring  careful  attention.  On  examination  next  day 
I  found  considerable  laceration  of  the  pelvic  floor  and  sent  for 
Dr.  Mcllwraith,  who  administered  an  anaesthetic  while  I  intro- 
duced the  necessary  sutures.  Without  a  careful  examination  I 
would  have  thought  there  was  only  a  slight  tear  of  the  perineal 
body  requiring  two  sutures,  instead  of  a  much  more  extensive 
laceration  requiring  ten  sutures. 

The  important  lesson  from  these  cases  is  this:  Dr.  A.  and 
I,  by  simply  introducing  sutures  through  the  skin  at  edges  of 
the  torn  perinseum,  as  was  formerly  (if  not  now)  frequently 
done,  might  have  got  a  certain  amount  of  union  with  an  ap- 
parently restored  perinseum.  As  a  matter  of  fact,  the  best 
result  we  could  obtain  by  such  faulty  operation  would  be  a 
ribbon-like  bit  of  skin  be- 
tween the  vulva  and  anus, 
with  the  pelvic  floor  de- 
stroyed and  a  woman  crip- 
pled for  all  time. 

Repair  of  Laceration  of 
Perineal  Body. — Minor  in- 
juries of  the  perineal  body 
or  fourchette  should,  how- 
ever, as  a  rule,  be  repaired 
at  once  without  anaesthetic. 
If  one  uses  a  sharp  needle 
and  thrusts  it  through  the 
skin  quickly  with  a  jab,  the 
patient  will  not  suffer  much. 
Such  sutures  may  be  intro- 
duced, but  not  tied,  before 
the  expulsion  of  the  pla- 
centa. After  the  expulsion 
of  the  placenta  tie  the  su- 
tures sufficiently  tight  to 
coapt    the  surfaces  without 

constricting  the  tissues.  It  has  been  well  said  (by  I  forget 
whom)  that  "a,  ligature  placed  for  the  arrest  of  haemorrhage 
can  hardly  be  drawn  too  tightly,  but  when  its  purpose  is  to  approx- 
imate surfaces,  and  especially  skin,  we  must  remember  that  after 


Fig.  171. — Sutures  in  Pelvic  Floor 
Tied  and  Two  Buried  Sutures  In- 
troduced into  Perine.\l  Tear. 


514  OBSTETRICAL    OPERATIONS 

simple  coaptation  is  effected  we  can  do  nothing  but  injury  in  using 
any  greater  degree  of  tension." 

Repair  of  Laceration  of  the  Pelvic  Floor  and  Perineal  Body, 
but  not  including  the  Sphincter  Ani. — Operation.  Place  the  pa- 
tient on  her  back  in  a  cross-bed  position,  with  legs  supported  by  a 


^ftRr 


Fig.    172. — Suture     Improperly  Fig.   173.  —  Fault  on   Left  Side 

Introduced,  does  not  Include  after  Tying. 

Muscle  on  Left  Side. 

leg-holder  or  by  an  assistant.  Anaesthesia  is  generally  necessary, 
chloroform  or  ether  being  used.  The  instruments  and  sutures 
required  are  needle-holder,  needles,  flat  retractors,  scissors  curved 
on  the  flat,  strands  of  silkworm  gut  in  sterilized  water,  strands  of 
catgut  or  kangaroo  tendon.  Some  prefer  a  handled  or  perineal 
needle,  while  others  use  curved  needles  threaded  with  carriers.  It 
is  more  convenient  to  use  the  needle  with  carrier  for  introducing 
the  sutures  within  the  vagina,  if  catgut  or  tendon  is  used.  For 
sutures  through  skin,  introduce  straight  or  slightly  curved  needles 
threaded  with  the  silkworm  gut.     Let  the  assistant  separate  the 


Fig.   174. — Suture  Properly   In-  Fig.  175. — Correct  Result. 

TRODucED,  Including  all  Torn 
Tissues. 

vulva  and  hold  upward  the  anterior  wall  of  the  vagina,  if  necessary, 
so  as  to  give  a  good  view  of  the  posterior  wall  of  the  vagina.  It 
is  generally  advisable  to  pack  the  vagina  above  the  tear  with 
iodoform  or  sterihzed  gauze  or  absorbent  cotton,  to  prevent  the 
discharges  from  obscuring  the  view.     There  will  probably  be  two 


LACERATIONS  OF  THE  PELVIC  FLOOK 


515 


tears  within  the  vagina  continuous  with  the  single  tear  of  the  peri- 
neal body.  These  two  vaginal  tears  run  upward,  one  on  each  side 
of  the  median  line,  but  one  usually  running  higher  than  the  other. 
The  three  tears  form  an  irregular  Y.  Introduce  the  first  suture 
on  a  level  with  the  upper  angle  of  the  higher  tear,  about  i  to  ^  inch 
from  its  margin.  After  pushing  the  needle  through  the  mucous 
membrane,  keep  the  point  well  outward  so  as  to  catch  all  the  tis- 
sues (muscles  and  fascia3)  which  have  been  torn.  While  doing  this 
make  the  needle  go  as  deeply  as  possible  without  entering  the  rec- 
tum. Then  turn  the  point  inward  and 
bring  it  out  at  the  center  of  the  tear. 
Re-enter  it  into  the  tissue  and  try  to 
include  all  the  torn  structures,  and 
push  it  through  the  mucous  mem- 
brane on  the  opposite  side  at  a  point 
corresponding  to  that  of  entrance. 
Then  let  the  assistant  hold  the  ends 
of  the  sutures  or  include  them  in  clip 
forceps.  Some  pass  these  sutures  at 
right  angles  to  the  vaginal  axis.  I 
think,  however,  that  the  method  re- 
commended by  Kelly  and  Robb  is 
better — i.  e.,  pass  the  needle  through 
the  tissues  rather  deeply  and  then  in 
a  direction  toward  yourself  or  down- 
ward, so  that  the  suture  at  the  floor 
of  the  tear  will  be  fully  ^  inch  (Robb 
says  1  inch)  lower  than  the  points 
of  entrance  and  exit.  To  introduce 
the  intra-vaginal  sutures  properly,  and 
especially  to  avoid  entering  the  rectum,  I  think  it  is  better 
to  introduce  one  forefinger  into  the  rectum.  One  cannot  be 
sure  in  any  case  that  the  rectum  is  aseptic,  and  should  always 
consider  that  the  finger  after  entrance  in  the  rectum  is  septic. 
Introduce  the  remaining  sutures  in  a  similar  manner  in  both  tears 
at  intervals  of  |  to  ^  inch  until  the  lower  end  of  the  vagina  is 
reached.  The  finger  may  be  kept  in  the  rectum  until  all  the 
vaginal  sutures  are  introduced.  Then  withdraw  the  finger  from 
the  rectum  and  wash  it  thoroughly.  Tie  the  sutures  in  the  order 
of  their  insertion   (not  too  tightly,  as  before  mentioned).     The 


Fig.  176.  —  Two  Sutures  in 
Perineum  Tied,  and  a  Su- 
perficial Introduced  be- 
tween them  and  Tied. 


516 


OBSTETEICAL    OPEEATIONS 


difficult  part  of  the  operation  is  now  completed.  The  tear  of  the 
perinseum  is  reduced  to  a  small  cavity,  which  can  be  closed  by 
sutures  introduced  through  the  margins  of  the  skin  deep  enough 

to  go  to  the  bottom  of  the 
cavity,  carried  transversely 
across  and  out  at  a  corre- 
sponding point  of  the  skin  on 
the  opposite  side.  Use  either 
catgut,  kangaroo  tendon,  or 
silkworm  gut  for  vaginal  su- 
tures. After  using  silkworm 
gut  leave  the  sutures  in  for 
three  weeks ;  then  have  an 
assistant  lift  up  the  anterior 
wall  of  the  vagina  and  retract 
the  labia  while  removing 
them.  Use  silkworm  gut  for 
suturing  the  tear  of  the  per- 
ineal body  and  leave  the  su- 
tures in  ten  days. 

Repair  of  Laceration  of 
the  Pelvic  Floor  and  the  Per- 
ineal Body  extending  into  the 
Rectum. — This  is  one  of  the 
most  difficult  operations  in 
the  whole  range  of  midwifery 
and  surgery.  There  is  not  a 
clean  cut  through  these  struc- 
tures, but  an  irregular  ragged 
tear  with  bruising  of  the  tis- 
sues. The  patient  will  almost 
certainly  be  in  an  exhausted 


X 


Fig.  177. — Tear  of  the  Perineal  Body, 
Extending  into  Rectum.  Four  catgut 
sutures  introduced  through  the  rectal 
mucous  membrane  on  one  side  and  ap- 
pearing on  torn  surface  3€  inch  from 
edge,  thence  through  opposite  torn  sur- 
face emerging  from  mucous  membrane, 
the  fourth  suture  including  the  torn  ends 
of  the  sphincter.  Additional  silkworm- 
gut  suture  passed  through  skin  some- 
what deeply  behind  the  ends  of  the 
sphincter,  across  to  the  other  side  and 
emerging  from  point  corresponding  to 
the  point  of  entrance. 


condition.  It  may  be  neces- 
sary to  wait  not  simply  one  day,  but  several  days,  before  operat- 
ing. It  is  often  better  to  wait  until  there  are  clean  granulating 
surfaces,  with  a  certainty  that  there  is  no  necrosed  tissue  in  the 
wounds.  There  should  be  a  skilled  assistant  in  addition  to  a 
nurse  and  anaesthetist.  If  one  has  not  acquired  considerable 
skill  in  the  performance  of  such  operations,  he  should  procure 
an  expert. 


LACERATIONS    OF    THE    PELVIC    FLOOli 


517 


Description  of  Operation.  Place  the  patient  on  her  back  across 
the  bed  and  prepare  as  before  described.  First  close  the  tear  in 
the  rectum  by  catgut  or  kangaroo  tendon  sutures.  Introduce  the 
first  suture  close  to  the  apex  of  the  tear  on  the  rectal  side,  through 
the  septum  across  to  the  other  side  of  the  tear,  coming  out  on  the 
rectal  side  at  a  point  corresponding  to  point  of  entrance,  and  tie 
at  once.  Litroduce  a  set  of  interrupted  sutures  until  the  sphincter 
is  reached.  Approximate  the  two  torn  ends  if  possible.  These 
ends  are  probably  far  apart,  and  not  easily  seen  because  retracted. 
Some  recommend  us  to  draw  out  these  torn  ends  with  a  tenaculum 
so  as  to  enable  us  to  pass  the  catgut  through  the  muscle.  The 
suture  connecting  these  torn  ends 
may  be  buried. 

Before  tying  the  last  suture 
introduce  one  or  two  sutures  of 
silkworm  gut  from  the  outside. 
The  first  of  these  is  especially  to 
assist  in  the  restoration  of  the 
sphincter,  and  is  really  the  old 
suture  recommended  by  Emmett 
and  Thomas  many  years  ago. 
Introduce  the  needle  (I  prefer  the 
straight  needle  for  this  purpose) 
behind  the  torn  end  of  the  sphinc- 
ter on  one  side,  push  it  upward 
and  inward  until  it  emerges  at  a 
point  near  the  united  rectal  edges 
about  f  inch  above  the  anus,  then 
reintroduce  it,  push  it  downward 
and  outward  until  it  comes  out 
at  a  point  behind  torn  end  of 
sphincter  on  the  other  side  and 
tie  it.  This  suture  is,  I  think, 
the  most  important  one  in  the 
restoration    of    the   functions    of 

the  sphincter  ani.  Introduce  a  second  silkworm-gut  suture  about 
half  an  inch  above  this  and  pass  in  and  out  in  a  direction 
parallel  to  the  former  suture,  but  do  not  tie  at  once.  These  are 
sometimes  called  reenforcing  sutures.  Now  inspect  the  bottom 
of  the  wound,  and  if  there  is  any  doubt  about  the  sutures  already 


Fig.  178. — Internal  Catgut  Su- 
tures Tied  with  Long  Ends  Pro- 
truding FROM  Rectum.  Exter- 
nal silkworm-gut  suture  also  tied. 
Buried  sutures  introduced  for  per- 
ineal tear. 


518 


OBSTETEICAL    OPEEATIONS 


introduced  and  tied  on  the  rectal  side,  introduce  two,  three,  or 
more  buried  catgut  or  kangaroo-tendon  sutures  or  a  continuous 
running  suture. 

Then  repair  the  pelvic  floor  as  before  described  by  introducing 
catgut  sutures,  commencing  at  the  apex  of  the  tear,  tying  and 
cutting  short  the  sutures  as  they  are  introduced.  Or  if  silkworm 
gut  is  used,  leave  for  three  weeks  as  in  last  operation.  Then 
introduce  your  silkworm  gut  transversely  through  what  remains 
of  the  torn  perineal  body.     Probably  only  two  or  three  sutures 

will  be  required  to  complete  this 
part  of  the  operation.  Then  tie 
these  sutures,  commencing  with  the 
lowest — i.  e.,  the  second  reenforc- 
ing  suture. 

These  sutures  are  sometimes 
left  about  two  inches  long  and 
fastened  together  at  their  ends  or 
cut  short  near  the  knots.  In  the 
latter  case  the  sharp  ends  often 
cause  pain;  in  such  cases  the  of- 
fending piece  of  gut  should  be 
readjusted. 

After-treatment.  Separate  the 
labia  and  cleanse  the  parts  by  a 
gentle  stream  of  lysol  or  sublimate 
solution  or  squeeze  the  solution  from 
a  ball  of  soaked  absorbent  cotton. 
Make  adjacent  parts  clean  and  dry, 
apply  the  antiseptic  vulvar  pad, 
place  patient  in  bed  on  her  back.  After  the  slighter  operations 
it  is  not  necessary  to  bind  the  legs  together ;  sometimes,  but  not 
always,  it  is  advisable  to  do  so  after  the  more  serious  ones.  The 
patient  may  be  allowed  to  turn  slowly  in  bed  and  at  the  same  time 
to  flex  both  thighs  together  to  a  slight  extent.  Catheterization  is 
only  to  be  done  when  actually  necessary.  Give  castor  oil  or  a 
mild  saline  cathartic,  such  as  sodium  phosphate,  Rochelle  salt,  or 
magnesium  citrate,  on  the  evening  of  or  the  next  morning  after  the 
operation,  or  perhaps  both.  Endeavor  to  get  the  bowels  moved 
before  hard  faeces  are  formed  and  before  the  sphincter  has  recov- 
ered its  tone  after  the  ordinary  relaxation  produced  during  labor. 


Fig.    179. 


-Perineal 
Tied. 


Sutures 


INDUCTION    OF    ABORTION  519 

Some,  however,  prefer  to  wait  two  or  three  days  and  then  give 
the  cathartic,  and  follow  some  hours  after  with  careful  adminis- 
tration of  half  a  pint  of  warm  sweet  oil,  the  enema  to  be  repeated 
in  four  to  six  hours  if.  necessary.  When  the  vulvar  pads  are 
changed,  and  after  catheterization,  voiding  urine,  or  movements 
of  the  bowel,  cleanse  the  parts  after  separating  the  labia  as  before 
described.  In  most  cases  a  vaginal  douche  of  half  to  a  pint 
of  ^-1  per  cent,  solution  of  lysol  may  be  given  in  the  gentlest 
possible  way  night  and  morning  for  cleansing  purposes.  Keep 
the  patient  in  bed  two  weeks  after  the  small  and  three  weeks 
after  the  larger  operations. 

Notwithstanding  the  unfavorable  location  and  the  usual  bruis- 
ing of  the  tissues  the  results  of  these  operations  are  generally  good. 
If  only  partial  union  takes  place,  always  perform  a  second  opera- 
tion in  ten  days  or  two  weeks.  If  some  sloughing  occurs,  wait 
until  the  necrosed  tissues  separate.  I'reshen  the  granulating 
surfaces  as  before  described  and  suture. 

INDUCTION  OF  ABORTION 

The  methods  of  inducing  abortion  are  to  a  large  extent  those 
which  have  already  been  described  under  immediate  active  inter- 
vention in  inevitable  abortion. 

Vaginal  Tamponade. — When  successful,  it  has  a  great  advantage 
in  not  destroying  the  ovum.  The  introduction  of  the  uterine  sound 
into  the  uterus,  and  turning  it  round  to  be  sure  of  rupturing  the 
egg-shell,  is  an  old-fashioned  and  frequently  unsatisfactory  method 
of  inducing  abortion.  Such  a  procedure  frequently  causes  that  dan- 
gerous condition  which  is  known  as  incomplete  abortion.  I  should 
never  recommend  the  use  of  the  sound  alone,  but  rather  in  con- 
junction Vvdth  the  vaginal  tamponade.  This  combined  procedure 
with  sound  and  tampon  requires  but  little  skill  and  involves  very 
sUght  danger.     It  may  be  repeated  daily  for  a  week  if  necessary. 

Rapid  Dilatation  of  Cervix  and  Curettement  is  the  most  certain 
and  satisfactory  method  in  skilled  hands.  It  is,  however,  an 
"  operation  "  requiring  as  a  rule  an  assistant  to  administer  an 
ansesthetic  and  involving  a  certain  amount  of  danger.  In  country 
practice  the  other  methods  are  simpler  and  safer. 

Operation.  Prepare  the  patient  as  before  directed;  anaesthe- 
tize; introduce  a  perineal  retractor  and  pull  backward;  seize  the 


520  OBSTETEICAL    OPEEATIONS 

anterior  lip  of  the  cervix  with  a  volsella  forceps  and  draw  well 
downward.  Dilate  the  cervix  if  necessary  by  artificial  dilator  or 
otherwise.  Introduce  the  finger  or  a  curette  into  the  uterine 
cavity  and  remove  completely  the  contents  of  the  uterus.  Then 
administer  an  intra-uterine  douche  of  weak  lysol  solution  and 
afterward  pack  with  iodoform  gauze. 

The  cervical  dilators  most  commonly  used  in  Canada  are 
Hegar's  dilators  or  some  modification  of  them,  such  as  those  of 
Leiter  or  Hanks,  or  MacNaughton-Jones,  and  the  Goodell's  metal- 
lic expanding  dilator  or  some  modification  of  it,  such  as  that  of 
Palmer.  The  metallic  dilator  is  more  rapid  in  action  than  the 
graduated  vulcanite  and  aluminum  bougies,  but  is  considered  by 
many  to  be  more  dangerous.  Tents,  so  commonly  used  at  one 
time,  have  been  to  a  great  extent  discarded,  because  of  the  diffi- 
culty of  making  them  aseptic. 

INDUCTION  OF  PREMATURE  LABOR 

Premature  labor  is  labor  occurring  between  the  twenty-eighth 
week  of  pregnancy  and  full  term.  Induction  of  premature  labor 
is  mechanical  interference  to  excite  uterine  contractions  and  bring 
on  labor  at  this  period.  The  indications  for  the  induction  of  pre- 
mature labor  are :  a  contracted  pelvis,  causing  defective  propor- 
tion between  the  child  and  mother;  a  head  found  too  large  or 
prematurely  ossified  in  previous  labors ;  a  dangerous  illness  of  the 
mother  from  excessive  vomiting,  albuminuria,  ursemic  convul- 
sions, chorea  with  mania,  organic  disease  of  heart,  lungs,  liver; 
irreducible  displacements  of  uterus ;  placenta  praevia ;  over-disten- 
tion  of  the  uterus  from  dropsy  of  amnion;  the  death  of  children 
in  utero  in  the  latter  part  of  former  pregnancies. 

Method  of  Induction  of  Premature  Labor. — The  method  most 
commonly  adopted,  the  world  over,  when  no  special  urgency  is 
required,  is  that  of  Krause  with  perhaps  the  help  of  fingers  or 
hydrostatic  dilators,  or  both,  after  dilatation  of  the  cervix  has  com- 
menced. The  patient  is  prepared  properly  and  placed  in  the  cross- 
bed  position,  the  bladder  and  rectum  being  emptied  and  the  exter- 
nal parts  and  vagina  thoroughly  cleansed.  A  posterior  speculum  is 
introduced,  and  the  anterior  lip  of  the  cervix  is  seized  with  a  bullet 
or  volsellum  forceps  and  drawn  down.  One  thus  has  a  good  view 
of  the  parts  and  can  use  the  bougie  without  touching  the  vaginal 


INDUCTION    OF    PEEMATURE    LABOR  521 

wall,  and  therefore  without  danger  of  carrying  vaginal  germs  (if 
any  are  left  after  the  cleansing  process)  into  the  uterine  cavity. 
A  flexible  gum-elastic  bougie  12-14  English  size  (which  has  been 
previously  .sterilized  by  boiling  for  ten  minutes  and  then  placed 
in  a  lysol  solution  1-20  or  a  bichloride  solution  1-1000  from  which 
it  may  be  taken  for  use)  is  passed  into  the  cervical  canal,  and  then 
pushed  up  gently  between  the  membranes  and  the  uterine  wall  as 
far  as  possible. 

The  bougie  should  pass  up  into  the  uterus  7  or  8  inches,  leaving 
about  1  or  2  inches  in  the  vagina.  In  the  first  attempt  it  is  pushed 
along  the  posterior  uterine  wall.  One  should  try  to  avoid  two 
things :  puncture  of  the  membranes  and  detachment  of  a  portion 
of  the  placenta.  If  the  bougie  meets  with  any  resistance,  it  is  with- 
drawn a  certain  distance  and  again  pushed  upward,  allowing  it  to 
take  its  own  direction.  If  it  again  meets  with  resistance,  it  is  with- 
drawn and  pushed  in  another  direction,  say  to  the  right  or  left  or 
front,  and  when  it  is  started  on  the  new  route  it  is  allowed  again  to 
take  its  own  direction  as  far  as  possible.  The  bougie  may  be  used 
without  a  stylet,  and  probably  the  majority  of  physicians  prefer 
this  method.  If  the  stylet  is  used  there  is  greater  danger  of 
puncturing  the  membranes.  To  avoid  this  the  bougie  is  pushed 
with  stylet  only  to  the  internal  os  or  1  inch  past  it,  keeping  close 
to  the  posterior  uterine  wall.  Then  an  assistant  holds  the  stylet 
while  the  bougie  is  pushed  off  it  into  the  upper  uterine  cavity. 

The  greater  part  of  the  bougie  is  now  in  the  uterine  cavity,  and 
it  is  hoped  that  the  tip  has  reached  the  fundus.  Sometimes,  but 
not  often,  one  can  be  certain  of  this  from  the  sensation  produced 
on  the  outside  hand  pressing  on  the  fundus.  An  inch  or  two  of  the 
bougie  is  outside  the  cervix  in  the  vagina.  Introduce  an  iodoform 
vaginal  tampon,  first  around  the  exposed  part  of  the  bougie,  then 
over  its  end.  The  tampon  should  be  sufficiently  tight  to  prevent 
protrusion  of  the  bougie  from  the  uterus.  Still  greater  distention 
of  the  vault  of  the  vagina  with  a  tightly  packed  plug  can  do  no 
harm,  and  is  likely  to  help  the  intra-uterine  portion  of  the  bougie 
in  inducing  uterine  contractions. 

Although  the  method  described  is  excellent  in  all  respects,  the 
speculum  and  volsellum  forceps  are  not  necessary,  at  least,  in  all 
cases.  The  index  or  index  and  middle  finger  are  introduced  up 
to  the  cervix  to  act  as  a  guide.  Then  the  bougie  is  passed  as 
before  directed  into  the  uterine  cavity. 


522  OBSTETEICAL    OPEKATIONS 

Never  use  a  catheter  instead  of  a  bougie,  because  of  the  danger 
of  admitting  air  into  the  uterine  cavity. 

Otlier  methods  are  mentioned  in  text-books.  Some  of  these  are 
worse  than  useless,  and  others  which  are  useful  under  certain  cir- 
cumstances will  be  described  under  Accouchement  Force.  Among 
former  methods  which  have  been  generally  discarded  are  puncture 
of  the  membranes  (dangerous  to  both  child  and  mother) ;  vaginal 
douches  (generally  uncertain  and  inefficient);  Cohen's  method  of 
passing  catheter  between  the  membranes  and  uterine  walls,  and 
injecting  slowly  seven  or  eight  ounces  of  warm  water  (unsatis- 
factory and  dangerous) ;  administration  of  oxytocics,  such  as  ergot 
(generally  ineffective  and  dangerous) ;  Pelzer's  method  by  injection 
of  three  ounces  of  sterilized  glycerine  between  the  membranes  and 
the  uterine  wall  (dangerous). 

ACCOUCHEMENT  FORCE 

This  term  is  applied  to  an  operation  which  includes  two  pro- 
cedures: (1)  rapid  dilatation  of  the  cervix;  (2)  rapid  delivery  of 
foetus  and  placenta.  In  former  times  the  operation  was  some- 
times performed  with  considerable  violence.  The  hand  was 
forced  hurriedly  through  the  cervical  canal  into  the  uterine  cavity. 
The  hand  after  its  introduction  quickly  grasped  a  foot,  turned, 
and  extracted  the  child  as  rapidly  as  possible.  The  results  were 
often  bad  and  the  operation  for  some  time  became  unpopular. 
It  appears  to  be  coming  again  into  favor.  We  are  told  that 
the  improvements  in  the  methods  of  dilatation  and  the  introduc- 
tion of  better  surgical  methods  have  greatly  enlarged  the  scope 
of  the  procedure.  While  these  statements  are  true  to  a  certain 
extent,  we  have  to  recognize  the  fact  that  the  operation  is  still 
extremely  dangerous,  especially  in  the  hands  of  the  modern  stren- 
uous obstetrician  who  desires  to  accomplish  as  much  in  one  hour 
as  another  can  manage  with  safety  only  in  three  or  four. 

When  speaking  of  placenta  praevia  I  referred  to  a  case  where 
a  prominent  and  skilful  practitioner  of  Toronto  caused  rupture 
of  the  uterus  by  a  moderate  traction  on  the  child  after  version. 
Whitridge  Williams  recently  published  the  following  report:  A 
patient  in  her  sixth  pregnancy  had  repeated  haemorrhages  due  to 
placenta  prsevia.  During  an  examination  after  admission  to  the 
hospital  such  profuse  haemorrhage  occurred  that  immediate  inter- 


ACCOUCHEMENT    FORCE  523 

ference  was  necessary.  Dr.  Williams  intended  merely  to  dilate 
the  OS  sufficiently  to  allow  the  introduction  of  two  fingers  for 
bipolar  version,  but  the  cervix  yielded  so  readily  that  he  com- 
pleted dilatation  easily  .and  apparently  without  any  injury  by 
Harris's  method.  Subsequently,  however,  after  death  an  exam- 
ination showed  that  in  addition  to  a  deep  tear  of  the  cervix,  which 
had  been  discovered  and  sutured,  there  was  a  rupture  of  the  uterus 
extending  from  the  cervical  tear  up  to  the  contraction  ring. 
Such  an  accident  in  the  practice  of  a  careful  and  conscientious 
expert  should  impress  upon  all  the  dangers  connected  with  such 
procedure. 

The  essential  element  in  accouchement  force  is  rapid  dilata- 
tion of  the  cervix  uteri ;  it  is  occasionally  indicated  in  cases  of 
eclampsia,  haemorrhage  from  separation  of  placenta  (ante-partum), 
prolonged,  especially  dry,  labor,  various  conditions  necessitating 
the  induction  of  abortion  or  premature  labor.  Most  of  these 
conditions  have  already  been  discussed,  but  I  desire  to  make 
certain  repetitions. 

Where  eclampsia  occurs  during  pregnancy  while  the  cervix  is 
still  intact,  it  is  better  promptly  to  treat  the  toxaemia  and  result- 
ing convulsions.  When  eclampsia  occurs  after  effacement  of  the 
cervix  or  early  in  labor,  do  two  things  :  treat  the  condition,  hasten 
delivery.  In  haemorrhage  from  placenta  praevia,  artificial  dilata- 
tion is  very  dangerous  and  should  never  be  done. 

Rapid  Dilatation  of  the  Cervix  Uteri. — Many  of  the  pro- 
cedures and  instruments  recently  used  aid  us  materially,  but  all 
involve  some  danger.  The  following  may  be  considered:  fingers 
and  hands,  elastic  and  inelastic  bags,  metallic  dilators,  cervical 
incisions. 

Fingers  and  Hands.  No  instruments  yet  devised  are  equal  to 
the  fingers  and  hands  intelligently  used  for  rapid  dilatation  of  the 
cervix.  The  best  method  of  rapid  dilatation  of  the  cervix  is  that 
recommended  by  Harris.  Push  the  index  finger  to  its  largest 
diameter  through  the  os  if  necessary.  Then  insert  the  tijDS  of  the 
thumb  and  index  fingers  together  within  the  os.  This  is  the  impor- 
tant thing  in  the  procedure.  Slide  the  thumb  along  the  index 
finger  in  a  direction  away  from  its  tip,  and  also  finger  along  the 
thumb.  One  can  put  much  force  in  this  movement  without  turn- 
ing the  hand  and  generally  cause  considerable  dilatation.  After 
this  has  been  accomplished  introduce  the  tip  of  the  second  finger 


524 


OBSTETEICAL    OPERATIONS 


with  those  of  the  thumb  and  index  finger.  Then  shde  the  thumb 
and  two  fingers  over  each  other.  Then  introduce  successively 
the  third  and  fourth  fingers,  and  flex  all  the  fingers  while  you  are 
sHding  the  thumb  over  the  index  and  second  fingers.  This  can 
be   better  understood   after   examining  the   accompanying   dia- 


Fig.  180. — Diagrams  Illustrating  Manual  Dilatation  of  Cervix  (Harris). 


grams.  Another  method  frequently  adopted  is  to  introduce  suc- 
cessively one,  two,  three,  and  four  fingers,  forming  all  in  the  shape 
of  a  cone  and  always  pressing  upward,  while  with  the  other  hand 
counter-pressure  is  made  over  the  fundus  uteri  through  the  abdom- 
inal wall.  Others  prefer  to  use  both  hands  and  introduce  the 
two  index  fingers  back  to  back. 

Elastic  and  Inelastic  Bags.  About  the  middle  of  last  century 
Carl  Braun  devised  an  elastic  bag  called  a  colpeurynter,  which  he 
placed  in  the  vagina  and  then  distended  it  with  a  view  of  stopping 
haemorrhages  and  dilating  the  cervix.  Shortly  after  Barnes  used 
elastic  fiddle-shaped  dilators  for  the  cervix.  These  were  used  for 
many  years,  but  have  recently  given  place  largely  to  Champetier 
de  Ribes's  bags,  which  are  much  used  on  the  Continent,  in  Great 
Britain,  the  United  States,  and  Canada. 

The  de  Ribes  hydrostatic  dilators  are  conical  bags  made  of 
inelastic  waterproofed  silk.  Instead  of  the  set  of  bags  our  dealers 
in  Canada  generally  have  only  the  largest  size.  The  base  of  the 
large  bag  measures  3^  inches,  and  the  bag  tapers  6  inches  to  the 
apex,  which  has  a  diameter  of  J  inch.     The  dilator  after  being 


ACCOUCHEMENT    FORCE 


525 


sterilized  is  folded  along  its  long  axis,  caught  in  a  specially  designed 
forceps,  and  passed  gently  through  the  os  and  cervical  canal,  if 
not  effaced,  into  the  uterine  cavity.  It  is  generally  better  to  use 
a  speculum  and  get  a  full  view  of  the  cervix.  The  anterior  lip  is 
then  seized  with  a  volsella  while  the  bag  is  introduced.  The  bag 
is  sometimes  introduced  before  the  membranes  are  ruptured,  but 
this  is  not  safe  because  its  distention  generally  causes  intense  pain 
by  the  sudden  stretching  of  the  uterine  muscular  fibers,  as  in  acci- 
dental concealed  haemorrhage. 

Previous  dilatation  if  required  may  be  effected  by  some  arti- 
ficial dilator.  A  fountain  douche  is  then  attached  to  the  nozzle 
of  the  dilator,  and  as  the  fountain  is  raised  the  lysol  solution  runs 
into  the  bag.  As  soon  as  the  latter  is  sufficiently  filled  to  insure 
its  retention  within  the  uterine  cavity  the  forceps  is  withdrawn. 
About  22  ounces  may  be  injected.  If  this  cannot  be  accom- 
plished with  the  elevated  fountain,  and  full  distention  is  required, 
a  Higginson  syringe  should  be  used.  After  distention  the  stop- 
cock is  turned  to  retain  the  solution.  Twenty-two  ounces  will 
cause  a  maximum  circumference  of  about  13  inches;  18  ounces, 
10  inches ;  15  ounces,  8  inches.  As  soon  as  the  cervix  is  sufficiently 
dilated  the  bag  is  expelled  by  the  uterine  con- 
traction. In  case  of  head  presentation  the  bag 
should  be  fully  distended.  If  rapid  dilata- 
tion is  desired  steady  or  intermittent  trac- 
tion may  be  made  on  the  tube.  The 
steady  traction  is  sometimes  made  by 


the  attachment  to  the  tube  of  a 
slight  weight  running  over  a  pulley 
at  the  foot  of  the  bed.     The  ten- 
sion of  the  bag  within  the  uterus 
may  be  alternately  increased  and 
diminished  by  raising  and  lowering 
the  fountain  of  the  douche  syringe. 
While  these  different  procedures  may  occasionally  be  useful, 
it  is  generally  safer  and  quite  sufficient  to  leave  the  bag  quietly 
in  position  after  introduction.     This  large  foreign  body  will  gen- 
erally excite  uterine  contractions,  and  then  Nature  can  complete 


Fig.  ISl. — Champetier  de  Ribes's 
Balloon    (Williams).      x  ^. 


526 


OBSTETEICAL    OPERATIONS 


the  dilatation  safely  and  efficiently.  Traction  may  sometimes 
cause  rupture  of  the  lower  segment  of  the  uterus,  just  as  it  not 
infrequently  does  in  the  case  of  traction  on  the  leg  after  version 
for  placenta  praevia. 

It  is  stated  that  the  waterproofed  silk  of  the  de  Ribes  balloon  is 
more  durable  than  the  rubber  of  the  Barnes  bag,  but  I  have  found 
both  perishable.    I  fear  that  the  silk,  even  when  carefully  prepared, 


Fig.  182. — Champetier  de  Ribes's  Bal- 
loon READY  FOR  INTRODUCTION  (Will- 
iams) . 


is  poor,  frail  stuff,  and  when 
kept  for  a  time  becomes  dry 
and  hard.  It  then  cracks  and 
breaks  up  when  manipulated. 
These  bags,  whether  made  of 
rubber  or  prepared  silk,  have 
proved  most  unsatisfactory  in  the  hands  of  many  country  prac- 
titioners for  the  reasons  mentioned.  The  de  Ribes  bags,  however, 
have  been  largely  used,  especially  in  maternity  hospitals.  While 
visiting  the  Sloan  Lying-in  Hospital  of  New  York  last  year,  I  was 
surprised  to  learn  the  frequency  of  the  use  of  the  de  Ribes  and 
the  Voorhees  cone  bags.  It  appeared  to  be  a  matter  of  routine 
in  certain  classes  of  cases,  without  any  consideration  of  other  and 
simpler  methods. 

The  perishable  nature  of  the  silk  bag  is  not  its  only  drawback. 
When  distended  within  the  uterine  cavity  it  is  a  large  foreign  body 
13  inches  in  circumference,  which  frequently  displaces  the  present- 
ing part  and  permits  prolapse  of  the  cord.  I  have  endeavored  to 
show  both  the  advantages  and  the  disadvantages  of  this  much 
used  bag.  It  occupies  an  important  place  in  midwifery,  but 
the  place  is  somewhat  limited  for  practice  outside  of  maternity 
hospitals. 

Voorhees's  Inelastic  Rubber  Cones.  Voorhees,  of  New  York, 
uses  a  cone-shaped  bag  somewhat  similar  to  the  de  Ribes,  but 
shorter  and  stronger.  Dickinson  tells  us  that  this  simple,  strong, 
short  cone,  inelastic,  thin  enough  to  slip  in  when  rolled  wherever 
the  finger-tip  will  pass,  with  no  stop-cock  to  get  out  of  order,  is 
durable,  efficient,  and  inexpensive.     The  set  of  four  costs  $1.50, 


ACCOUCHEMENT    FORCE 


527 


while  the  de  RiV)cs  set  costs  $6.00.  I  now  carry  those  bags  in 
my  satchel  instead  of  the  de  Ribes  balloon.  The  \V)r)rhees  cone 
is  used  in  a  niaiuier  siiiiihir  to  thai  of  the  dr  Ribes  balloon,  but 
it  is  intnxhieed  witii  the  aid  of  any  slender  long-elainp  for- 
ceps. When  tlie  bag  is  distended  its  tube  is  clamped  by  an 
ordinary  forceps.  Slight  traction  on  the  tube  may  be  employed 
in  some  cas(vs. 

The  hych'ostatic  dilators  may  occasionally  be  used  in  cases  of 
placenta  prtevia  (slight  traction, if  any,  to  be  employed),  separation 
of  placenta,  and  for  the  induction  of  premature  labor  for  various 


Fig.  183. — Voorhees's  Dilating  Bags. 


causes;  or  they  may  be  used  in  conjunction  with  other  methods 
of  inducing  or  shortening  labor. 

Metallic  Dilators.  Various  dilators  have  been  constructed  for 
rapid  dilatation  of  the  cervix,  but  the  one  which  now  claims  special 
attention  is  that  designed  by  Bossi,  of  Genoa,  in  1890.  The  Bossi 
dilator  is  a  four-branched  uterine  dilator,  with  a  strong  screw  on 
the  handle  and  an  indicator  to  show  the  amount  of  the  dilatation. 
35 


528 


OBSTETRICAL    OPEEATIONS 


The  four  branches  when  closed  form  one  body  which  is  introduced 
within  the  os  uteri.  The  blades  are  sometimes  covered  with  rub- 
ber tubing  before  introduction.  After  insertion  the  blades  are 
separated  by  a  quarter  turn  of  the  screw  every  two  minutes.     It 

is  used  chiefly  for  cases  of  eclampsia 
when  rapid  delivery  is  indicated.  It 
should  never  be  used  in  cases  of 
placenta  prsevia. 

It  is  claimed  that  the  cervix  can 
be  safely  dilated  with  this  instru- 
ment in  from  twenty  to  sixty  min- 
utes. We  have  clear  evidence,  how- 
ever, from  many  operators,  that  this 
is  not  true  in  all  cases. 
It  frequently  causes 
serious  tears,  especially 
when  used  before  ef- 
facement  of  the  cervix. 
Diihrssen,  the  great 
advocate  for  cervical 
incisions  in  labor, 
has  published  in  con- 
siderable detail  his 
views  on  the  cases  re- 
ported on  the  Conti- 
nent and  has  expressed 
a  positive  opinion  that 
the  Bossi  dilator  is 
both  dangerous  and  in- 
efficient. On  the  other 
hand,  several  conserva- 
tive  obstetricians 
strongly  favor  it  as  an 
efficient  instrument  in 
certain  cases. 

Cervical  Incisions. — Although  incisions  of  the  cervix  in  labor 
have  been  made  by  various  obstetricians  for  at  least  a  century, 
we  are  especially  interested  in  the  work  of  Carl  Braun,  Skutsch, 
and  Diihrssen  during  the  last  twenty-five  years.  The  latter  has 
been  the  strongest  and  most  persistent  advocate  of  the  procedure 


Fig.  184. — Bossi's  Dilator. 


ACCOUCHEMENT    FORCE  529 

during  the  last  fifteen  years.  The  operation  is  incUcated  in  those 
rare  cases  of  extreme  rigidity  due  to  preexisting  disease  or  injury 
resulting  in  cicatrices  where  dilatation  cannot  be  effected  by  ordi- 
nary methods.  In  addition,  it  is  occasionally  indicated  in  rigidity 
from  unknown  causes,  but  not  nearly  so  often  as  recommended 
by  Diihrssen,  according  to  the  opinions  generally  held  in  Canada. 

As  this  operation  is  always  dangerous  it  is  important  to  have 
a  clear  idea  of  the  physiology  of  dilatation  of  the  cervix,  as  has 
been  explained  in  connection  with  normal  labor.  In  primiparce, 
dilatation  commences  at  the  internal  os  and  extends  downward 
to  the  external  os.  The  cervix  is  thus  effaced  before  dilatation 
of  the  external  os  occurs.  In  multiparae,  dilatation  of  the  external 
OS  generally  takes  place  to  some  extent  before  it  commences  at 
the  internal  os.  The  cervix  is  thus  not  effaced  until  labor  is 
considerably  advanced. 

Cervical  incisions  should  never  be  made  until  efTacement  of 
the  cervix  is  completed. 

Operation.  The  patient  is  properly  prepared  and  placed  on 
her  back  across  the  bed.  An  assistant  administers  an  anaesthetic. 
The  left  hand  is  passed  into  the  vagina,  leaving  the  thumb  outside. 
The  index  or  middle  finger  is  introduced  within  the  os  and  another 
finger  is  placed  outside  the  cervix.  These  two  fingers  will  gen- 
erally fix  the  cervix  and  serve  as  a  guide  for  the  scissors.  A  pair 
of  blunt-pointed  scissors  bent  at  the  knee  is  taken  in  the  right 
hand  and  introduced  along  the  fingers  within  the  vagina,  one 
blade  within  and  the  other  without  the  cervix,  and  an  incision  is 
made  with  one  or  two  cuts  up  to  the  vaginal  vault  on  each  side. 
These  two  lateral  incisions  may  be  sufficient.  If  not,  a  posterior 
incision  is  made.  There  are  now  three  incisions.  Diihrssen 
thinks  that  two  or  three  are  generally  sufficient,  although  in  one 
case  he  found  seven  incisions  necessary.  When  the  cervix  is 
yielding  Diihrssen  introduces  specula  which  are  held  by  an  assist- 
ant, while  he  fixes  the  cervix  with  a  volsellum  on  each  side  of  the 
site  of  the  incision  and  cuts  between  them.  He  also  thinks  that 
the  incisions  need  not  be  sutured,  because  the  unsutured  wounds 
heal  as  well  as  the  sutured. 

Immediate  dehvery  should  follow  the  incisions,  the  forceps 
being  applied  if  necessary.  If  haemorrhage  occurs  the  wounds 
should  be  sutured  if  possible.  If  this  cannot  be  done  a  utero- 
vaginal tampon  should  be  used.     Holmes,  who  recently  read  an 


530 


OBSTETRICAL    OPERATIONS 


excellent  paper  on  this  subject  before  the  Chicago  Gynsecological 
Society,  considers  that  in  view  of  the  post-partum  repair  which 
may  be  required  there  should  be  two  assistants  in  addition  to  the 
anaesthetist  for  this  operation. 

VERSION 

Version  means  turning  the  child  in  the  uterus  and  altering 
the  existing  presentation  to  one  more  favorable.  The  indications 
for  performing  this  operation  are :  a  presentation  of  the  shoulder, 
deformity  of  the  pelvis,  presentation  of  brow  or  other  malpresenta- 
tion  of  the  head,  placenta  prsevia,  prolapse  of  the  cord,  prolapse 
of  one  or  both  arms  or  of  an  arm  and  a  foot,  and  emergencies 
arising  from  eclampsia,  detachment  of  the  placenta,  rupture  of 
the  uterus,  etc.     It  is  positively  contra-indicated  when  there  is 


._.-. 1 


Fig.  185. — External  Ceph.alic  VER.iioN  (Pinard). 

retraction  of  Bandl's  ring  high  above  the  symphysis,  especially 
when  the  uterus  above  it  is  hard  like  a  bullet.  The  conditions 
which  should  be  present,  or  are  most  favorable  for  a  successful 
issue,  are  as  follows :   when  the  pelvis  is  roomy  and  the  child  not 


VEKSION" 


531 


unduly  large;  whoii  i]\v  u1(>nis  is  (lislciidcil  l)y  rKiuor  uiiuiii; 
when  the  os  is  dilated  or  dilatal)le;  when  the  uterine  walls  are 
not  tetanically  constricted  around  tiie  child. 

When  the  part  of  tlK>  cliild  that  is  brought  down  is  considered, 
version  is  divided  into  two 
classes:  (1)  cephalic,  when 
the  head  is  brought  down; 
(2)  pelvic,  including  podalic, 
when  the  pelvis  or  foot  is 
brought  down.  When  the 
methods  employed  to  turn 
the  child  are  considered  it 
is  classified  as  (1)  external, 
(2)  combined  external  and 
internal  or  bipolar,  and  (3) 
internal. 

External  Method. — In  this 
method  external  manipula- 
tion— i.  e., manipulation  over 
the  mother's  abdomen  alone 
— is  used.  The  best  example 
of  this  is  seen  in  the  con- 
version of  a  breech  into  a 
head  presentation.  The  op- 
erator may  stand  at  the  side 
of  the  patient  while  she  is 
lying  close  to  the  edge  of  the 
bed;  or  bet^veen  her  thighs 
when    she    is    placed   across 

the  bed.  Manipulations  should  be  made  between  pains,  not 
during  pains,  one  hand  being  on  the  breech  and  the  other  on 
the  head. 

Combined  or  Bipolar  Method. — Braxton  Hicks 's  way  of  per- 
forming this  is  very  common  in  England.  He  places  the  patient 
on  her  left  side  and  introduces  his  left  hand  into  the  vagina.  On 
the  Continent  and  in  America  it  is  generally  preferred  to  have 
the  patient  in  the  cross-bed  position,  the  operator  standing  between 
her  thighs.  In  all  cases  a  previous  knowledge  of  the  position  of  the 
child,  acquired  by  abdominal  palpation,  is  of  paramount  impor- 
tance.    If  it  is  a  head  presentation  this  should  be  converted,  first, 


Fig.   186. — Seizure   of  Foot   in   Inter- 
nal Podalic  Version  (Tarnier). 


532 


OBSTETEICAL    OPEEATIONS 


into  a  transverse.  It  has  now  to  be  decided  which  hand  the  opera- 
tor should  introduce  into  the  vagina.  The  right  hand  is  introduced 
when  the  child's  feet  are  turned  to  the  mother's  right  side,  and  the 
left  when  they  are  turned  to  her  left.  The  whole  hand  is  intro- 
duced into  the  vagina  and  two  fingers  into  the  uterus,  rupturing 
the  membranes,  if  this  has  not  already  occurred.  The  head 
should  be  pushed  up  with  the  internal  hand  and  the  breech  down- 
ward with  the  external.  The  conversion  into  a  breech  is  now 
completed.  In  this  turn  the  child's  back  should  be  turned  to  the 
fundus  of  the  uterus.     A  foot  should  now  be  seized  and  pulled 

downward  into  the  va- 
gina, while  the  external 
hand  is  transferred  to 
the  other  side  and  the 
head  pushed  upward. 
Sometimes  when  the  os 
is  not  fully  dilated  it 
will  be  found  impossible 
to  bring  the  foot  into 
the  vagina.  As  Jellett 
expresses  it,  the  os  may 
be  large  enough  to  ad- 
mit the  two  fingers  or 
the  foot  alone,  but  not 
large  enough  for  the 
foot  and  fingers  together. 
In  such  a  case  he  ad- 
vises that  the  foot  be 
brought  down  until  the 
toes  are  through  the  os 
internum.  Then  the  fin- 
gers should  be  drawn 
down  into  the  vagina 
and  an  endeavor  made 
to  push  the  cervix  over 
the  foot.  At  the  same 
time  the  external  hand  should  press  over  the  breech  through  the 
abdominal  walls,  so  causing  the  foot  to  descend.  The  foot  is  then 
again  seized  and  drawn  downward,  and  at  the  same  time  the 
head  is  pushed  upward  with  the  external  hand. 


Fig.  187. — Version:  Transverse  Presenta- 
tion, Back  Posterior,  Seizure  of  Upper 
Foot  (Williams). 


VEKSION 


533 


Internal  Method. --In  this  inothod  the  whole  hand,  not  the 
two  fingers  alone,  is  introduced  into  the  utcnnis.  The  same  pro- 
cedure as  in  the  bipolar  method  is  adopted,  but  the  greater  part 
of  the  work  is  accomplished  by  the  internal  hand.  Occasion- 
ally the  external  hand 
cannot  push  the  head 
up  while  the  foot  is 
being  brought  down.  In 
such  a  case  bring  down 
the  second  foot  and 
pull  both  feet.  If  trac- 
tion then  fails,  take  a 
strip  of  iodoform  gauze 
and  apply  it  to  one  or 
both  ankles  by  a  slip 
knot  or  clove  hitch. 
Traction  should  be 
made  on  this  strip  with 
one  hand  outside  the 
vagina,  and  at  the  same 
time  the  other  hand  in 
the  vagina  pushes  the 
head  upward  out  of  the 
false  pelvis  (Jellett). 

In  these  operations 
deep  anaesthesia  is  re- 
quired, not  alone  to 
render  the  abdominal 
walls  lax,  but  to  insure 
against  prolapse  of  the 
cord  brought  on  by  the 
straining  of  a  patient 
not  sufficiently  anaesthetized.  In  carrying  out  these  methods  of 
procedure  care  should  be  taken  not  to  use  too  great  force,  for 
fear  of  rupturing  the  uterus.  This  accident  is  not  apt  to  occur 
if  version  is  undertaken  soon  after  the  rupture  of  the  membranes, 
provided  the  operation  is  carefully  performed. 


^,,> 


Fig.  188. — Bipolar  Podalic  Version  (Bumm). 


CHAPTER  XXV 

OBSTETRICAL   OPERATIONS  {Continued) 

DELIVERY  WITH  THE  FORCEPS 

Prof.  Japp  Sinclair,  of  Manchester,  came  to  Canada  in  1897, 
and  told  us  that  the  obstetricians  were  the  providers  of  material 
for  the  gynaecologists  through  unskilful  use  of  the  midwifery  for- 
ceps. Baudeloque,  on  the  other  hand,  has  stated  that  the  mid- 
wifery forceps  is  the  most  valuable  instrument  that  has  yet  been 
invented.  We  believe  the  great  mass  of  obstetricians  in  all  civilized 
countries  indorse  this  statement,  and  conscientiously  and  intelli- 
gently use  the  forceps  to  shorten  the  suffering  and  diminish  the 
risks  at  childbirth.  No  one  will  deny  that  much  injury  is  done  in 
certain  cases  by  the  unskilful  use  of  the  forceps.  According  to  Sin- 
clair and  the  few  who  agree  with  him,  the  common  fault  is  the 
premature  use  of  the  forceps.  Dr.  Lapthorn  Smith,  of  Montreal, 
makes  the  very  serious  accusation  that  the  doctors  use  the  in- 
strument early  without  any  regard  to  the  condition  of  the  parts, 
simply  to  save  time.  This  is,  of  course,  not  a  new  charge,  and  we 
may  admit  that  some  physicians  apply  the  forceps  prematurely 
to  save  their  own  time  and  suit  their  own  convenience.  The  man, 
however,  who  does  such  a  thing  is  guilty  of  a  criminal  act.  Every 
physician  should  recognize  the  fact  that  premature  use  of  the  for- 
ceps is  always  dangerous,  and  should  make  it  a  positive  rule  in 
practice  never  to  use  the  forceps  through  a  partially  dilated  os. 
The  forceps  should  never  be  used  as  dilators. 

Milne  Murray  refers  to  a  form  of  spasmodic  rigidity  which  is 
especially  dangerous  for  forceps  delivery.  For  instance,  a  woman 
has  been  in  labor  many  hours.  After  a  time  an  examination 
during  an  interval  between  the  pains  shows  the  os  soft,  flabby, 
fairly  well  dilated  or  at  least  dilatable.  Some  chloroform  is  admin- 
istered and  the  forceps  are  slipped  over  the  head,  of  course  within 
the  OS.  During  the  following  pain  the  os  becomes  spasmodically 
534 


DELIVERY    WITH    TIIF.    FOIJCKPS  535 

contracted  round  the  licad  and  forceps  and  not  moi-e  Hum  half 
its  apparent  size.  Dr.  Murray  considers  such  a  condition  an 
example  of  uterine  incoordination,  or  uterine  sUnnmer.  Traction 
under  such  circumstances  will  tear  the  cervix  into  the  vaginal 
roof  with  sometimes  most  disastrous  results.  Careful  examina- 
tion, which  should  always  be  made  during  a  pain  as  well  as  dur- 
ing the  interval,  will  prevent  one  from  making  such  a  deplorable 
blunder. 

Reference  has  been  made  to  secondary  inertia.  It  is  of  course 
a  condition  which  involves  some  danger  as  to  the  use  of  the  for- 
ceps, but  it  should  not  be  considered  a  positive  contra-indication. 
Sometimes  it  is  more  dangerous  not  to  interfere  in  a  case  of  sec- 
ondary inertia  than  to  deliver  slowly  and  carefully  with  the  for- 
ceps. It  is  somewhat  confusing  to  a  student  to  be  told  that  the 
use  of  the  forceps  during  uterine  inertia  is  exceedingly  dangerous, 
and  afterward  to  learn  that  feebleness  of  pains  is  one  of  the  indica- 
tions for  the  use  of  the  forceps. 

While  we  should  avoid  the  premature  use  of  the  forceps,  we 
should  not  go  to  the  opposite  extreme  and  fail  to  use  them  when 
necessary.  In  former  times  when  the  forceps  were  used  less  fre- 
quently by  the  majority,  and  not  at  all  by  some,  that  horrible 
condition,  vesico-vaginal  fistula,  was  not  uncommon.  It  is  now 
comparatively  rare.  This  is,  however,  telling  a  small  part  of  the 
story.  Dr.  Murray  says  much  in  a  few  words  when  he  tells  us 
that  by  means  of  the  forceps  we  have  saved  hundreds  and  thou- 
sands of  weary  hours  and  preserved  countless  children  alive. 

The  suitable  conditions  of  the  patient  and  the  indications  for 
the  application  of  the  forceps  may  be  summarized  as  follows : 

Suitable  Conditions. — The  os  dilated  or  dilatable;  the  vagina 
and  internal  genitals  softened  and  dilatable ;  the  membranes  rup- 
tured; the  skull  of  child  sufficiently  large  and  firm;  the  head 
engaged  (with  rare  exceptions) ;  the  pelvis  sufficiently  large ;  the 
rectum  and  bladder  empty. 

The  Indications. — The  indications  for  the  use  of  the  forceps  are 
as  follows :  When  the  mother  is  in  danger  from  exhaustion  from 
prolonged  second  stage;  where  there  is  a  slight  pelvic  contraction 
and  the  choice  lies  between  the  use  of  the  forceps  and  version ; 
where  there  is  a  delayed  face  presentation,  especially  when  the 
chin  is  rotating  to  the  front ;  when  there  is  a  hsemorrhage  of  any 
kind,  or  rupture  of  the  uterus.     It  is  also  indicated  in  some  cases 


536  OBSTETEICAL    OPEEATIOi^S 

of  occipito-posterior  positions,  but  it  is  better  to  wait  as  long  as 
possible  or  correct  the  position  if  possible.  It  is  indicated  too 
when  the  child  is  in  danger  from  prolapse  of  the  cord,  threatened 
asphyxia  from  any  cause,  or  impaction  of  funis. 

This  list  of  indications  for  forceps  interference  is  practically 
that  found  in  standard  text-books,  but  it  is  neither  scientific  nor 
accurate.  One  should  consider  that  each  of  the  conditions  named 
may  render  the  use  of  the  forceps  advisable.  These  conditions 
have  been  discussed  in  former  chapters. 

As  before  stated,  the  second  stage  of  labor  should  be  as  short  as 
possible.  When  all  the  soft  parts,  from  cervix  uteri  to  the  vulva, 
inclusive,  are  softened  and  dilated  or  dilatable,  quick  delivery  of 
the  child  is  desired.  To  accomphsh  this  the  forceps  are  used  in 
certain  cases.  When  shall  we  use  them?  This  is  not  an  easy 
question  to  answer  definitely.  Milne  Murray  lays  down  a  rule  to 
which  he  attaches  much  importance.  ''A  direct  indication  for 
the  use  of  the  forceps  arises  whenever,  and  only  whenever,  we  are 


r 
I 
i 
t 

r 
I 
1 

1 

V 

1 

''■V, 

^ 

T 

.^ 

Fig.  189. — Abdomen  of  Primipar^  at  Term,  showing  Stri^. 

assured  that  the  danger  of  interference  has  become  less  than  that 
of  leaving  the  patient  alone."  He  claims  that  this  is  more  than  a 
mere  truism,  inasmuch  as  it  implies  that  the  use  of  the  forceps  is 
nearly  always  a  matter  of  individual  judgment.  He  considers 
that  there  is  no  accepted  set  of  rules  which  can  be  applied  to  every 
emergency. 


DELIVERY    WITH    THE    FOliCEI'S 


537 


At  the  Rotunda  a  definite  time  limit  for  the  second  stage  has 
been  recognized  for  several  years.  That  limit,  when  I  heard  last, 
was  four  hours.  The  same  limit  was  observed  in  St.  Mary's  and 
Queen  Charlotte's  Hospitals  for  some  time,  but  in  1897  the  max- 
imum duration  was  altered  from  four  to  two  hours.  Many  express 
the  opinion  that  the  time  ele- 
ment alone  is  not  a  proper 
basis  for  such  interference.  I 
quite  concur,  and  yet  I  believe 
firmly  in  the  time  limit,  al- 
though I  do  not  depend  upon 
that  alone.  I  also  doubt  wheth- 
er any  one  at  the  Rotunda,  St. 
Mary's,  or  Queen  Charlotte  de- 
pends on  the  time  element  a/one. 

I  saw  a  patient  recently 
in  consultation  with  a  very 
competent  and  careful  young 
practitioner.  The  parts,  I  was 
informed,  had  been  dilated 
about  eight  hours.  The  doctor 
was  trying  to  reach  a  conclu- 
sion whether  or  not  the  time 
had  arrived  "when  the  danger 
of  interference  had  become  less 
than  that  of  leaving  the  patient 
alone."     The  patient,  although 

tired,  was  not  suffering  acute  pain.  The  time  limitation,  if  ob- 
served, would  have  prevented  such  prolonged  delay  with  asso- 
ciated dangers.  I  think  the  maximum  duration  of  the  second 
stage  should  be  three  hours  for  primiparae  and  two  hours  for 
multiparas.  This  does  not  mean  that  in  all  cases  one  should  wait 
for  the  three  or  two  hours;  but  it  does  mean  that  in  no  ca.se 
should  one  wait  any  longer.  In  a  large  proportion  of  cases  it  is 
neither  necessary  nor  advisable  to  defer  the  application  of  the 
forceps  for  more  than  one  hour  after  full  dilatation  of  the  cervix, 
vagina,  and  vulva.  "When  the  passages  are  in  a  fit  state,  and 
Nature  fails  to  advance  the  head,  apply  the  forceps  "  (Simpson). 

Position  of  the  Patient. — The  lithotomy  position  for  the  patient 
is  generally  used  in  Canada,  the  United  States,  and  the  Continent 


Fig.  190. — The  Sxively  Stockixg- 
Drawers. 


538 


OBSTETRICAL    OPEEATIORS 


of  Europe.  We  think  it  is  much  better  than  the  left  lateral,  espe- 
cially in  all  cases  of  difficulty.  We  sympathize  with  those  who 
object  to  undue  exposure  and  cover  the  parts  as  well  as  possible. 
The  Snively  Stocking-Drawers. — The  best  available  protect- 
ing garment,  so  far  as  I  know,  is  the  combination  of  stockings 
and  drawers  designed  by  Miss  Snively.  They  are  made  of  can- 
ton flannel,  flannelette,  or  strong  factory  cotton.  They  are  re- 
tained in  position  by  means  of  tape  which  acts  as  a  belt  around 
the  waist,  preventing  the  possibility  of 
slipping.  They  are  adjustable  to  such  an 
extent  that  they  do  not  interfere  with 
the  operator,  as  they  are  open  both  back 
and  front  and  also  on  either  side.  In  ad- 
dition to  these  openings,  the  front  is  so 
arranged  that  it  may  be  allowed  to  drop 
down  away  from  the  abdomen  in  cases 
where  this  may  be  necessary  without  in- 
terfering with  the  protection  afforded  by 
the  combination  elsewhere. 

It  is  generally  advisable  to  fasten  the 
thighs  in  the  flexed  position.  I  generally 
use  for  this  purpose  Robb's  leg-holder. 
One  end  is  fastened  to  a  leg  below  the 
knee.  The  rest  of  the  band  is  passed  over 
one  shoulder,  across  the  back,  under  the 
other  shoulder,  and  the  other  end  of  the 
band  is  fastened  to  the  other  leg  below  the 
knee.  The  old-fashioned  sheet  shng  is 
quite  satisfactory.  It  is  made  by  two 
persons  holding  diagonally  opposite  cor- 
ners of  a  sheet  and  rolling  the  hanging  portion  around  the  part 
held  taut  until  a  sort  of  rope  is  formed.  One  end  of  this  is  tied 
to  the  leg  below  the  knee,  or  sometimes  to  the  thigh  near  the 
knee.  The  shng  is  passed  (like  Robb's  strap)  over  one  shoulder, 
under  the  other,  and  the  end  is  tied  to  the  other  leg.  If  the  band 
or  sling  is  properly  adjusted  it  tends  to  abduct  or  separate  the 
knees ;  while  a  shng  passed  under  the  knees,  round  the  neck,  with 
the  ends  then  tied  together  (as  sometimes  recommended)  would 
tend  to  draw  the  knees  together  and  would  be  extremely  uncom- 
fortable for  the  patient. 


Fig.  191. — Pattern  of 
Snively  Stocking- 
Drawers. 


ny.LIVKIlV    WITTT    THE    FOKCKPS 


539 


Kinds  of  Forceps. — There  are  three  kinds  of  forceps:   (1)  short, 
straight;  (2)  loiiu',  two  curves;    (3)  axis-traction.     Each  blade  of 


Fig.  192. — Patient  on  table  in  lithotomy  position,  wearing  the  Snively  stocking- 
drawers;  vulva  covered  with  small  towel  fastened  with  safet5^-pins,  Robb's 
leg-holder  applied.  Upper  part  of  patient  hidden  from  view  by  curtain 
stretched  across  the  room  (Burnside  Lying-in  Hospital). 

the  long  forceps  and  the  axis-traction  forceps  has  two  curves:  a 
cephalic  curve  to  adapt  itself  to  child's  head  and  a  pelvic  curve  to 
adapt  itself  to  shape  of  pelvis,  especially  when  the  head  is  high. 


Fig.  193. — Lower  half  ul'  li.Awl  IuiuulI  up  iurI  pinncil.  leaving  sufficieut  exposure  to 
apply  the  forceps  or  operate  on  pelvic  floor  and  perinseum. 


There  is  also  a  curve  on  each  traction  rod,  and  sometimes  a  third 
curve  on  the  shank,  as  in  Galabin's  axis-traction  forceps.     There 


540 


OBSTETEICAL    OPEEATIONS 


are  three  kinds  of  locks  :  English,  Smellie,  with  shoulder  projecting 
from  each  half  of  instrument,  the  two  shoulders  fitting  into  one 


Fig.  194. — Making  Sheet  Sling,  First  Stage. 

another  by  inclined  planes :   French,  pivot  having  a  projection  or 
tenon  on  one  arm  which  is  inserted  into  a  cavity  or  mortise  on  the 


Fig.  195. — Making  Sheet  Sling,  Second  Stage. 


DI'IJVKRY    WITU    THE    FORCEPS 


541 


other,  with  a  screw  to  hold  them  in  position;  German,  one  arm 
bitin<;-  into  the  other,  while  a  pin  on  one  fits  into  a  notch  on  the 
other. 

Choice  of  Forceps. — The  varieties  of  forceps  mentioned  are  the 
short,  long,  and  the  modified  long — i.  e.,  the  long  forceps  with  axis- 
traction  appliances.  The  object  of  Tarnier  in  making  his  instru- 
ment was  to  have  it  so  adjusted  that  the  force  in  traction  should 


Fig.  196. — Sheet  Sling. 


lie  in  the  true  axis  of  the  pelvis  at  all  its  planes,  and  that  no  part 
of  that  force  should  be  either  wasted  or  used  in  such  a  way  as  to 
cause  injury. 

One  can  understand  a  part  of  this  better  by  considering  the 
action  of  the  ordinary  long  forceps  when  applied  at  the  superior 
strait.  The  axis  of  the  superior  strait  points  toward  the  lower 
part  of  the  sacrum.  The  perinseum,  the  coccyx,  and  a  small  por- 
tion of  the  sacrum  being  in  front  of  the  axis  of  the  brim  prevent 
the  handles  from  being  pushed  back  to  allow  direct  traction. 
Consequently,  part  of  the  force  of  traction  is  wasted  in  dragging 
the  head  against  the  symphysis  pubis.     This  defect  in  the  ordinary 


542 


OBSTETRICAL    OPEEATIONS 


long  forceps  was  clearly  recognized  more  than  one  hundred  years 
ago,  and  many  devices  were  tried  to  overcome  the  difficulty,  with 


Fig.  197. — Simpson's  Forceps,  Cephalic  Curve. 

a  certain  amount  of  success.     One  of  the  most  common  devices 
is  known  as  Pajot's  maneuvers  (Fig.  202). 

Tarnier  solved  the  problem  in  1877  by  attaching  one  traction 
rod  to  each  blade  of  the  forceps  and  fastening  both  rods  to  a  handle 
or  crossbar.     His  original  instrument  was  rather  clumsy,  and  he 


Fig.  198. — Simpson's  Forceps,  Pelvic  Curve. 

made  many  improvements  on  it  before  his  death.  Many  slight 
modifications  have  been  made  in  various  parts  of  the  world.  As 
a  rule,  all  that  are  constructed  on  the  Tarnier  axis-traction  prin- 
ciple are  good.     But  no  such  modification  as  the  attachment  of 

tapes  by  loops  passed  through  the 
fenestrse  of  the  blades  or  the  perineal 
curve  of  Galabin  is  satisfactory.  I 
fear  that  even  Neville's  forceps,  so 
highly  lauded  by  the  Rotunda  men, 
is  not  a  true  axis-tractor. 

I  used  the  Milne  Murray  modifi- 
cation of  Tarnier  with  much  satis- 
faction for  about  ten  years,  but  when 
in  Paris  three  years  ago  I  got  the 
latest  Tarnier  forceps  as  recom- 
mended by  Pinard.  After  using  this 
instrument  for  a  time  I  found  it 
unsatisfactory.  I  then  decided  to 
either  go  back  to  the  Milne  Murray  instrument  or  choose  the 
Porter  Mathew  forceps,  which  Dr.  Mcllwraith  has  used  for  some 


Fig.    199.  —  Lock   of    English 
Forceps. 


DELTVEKY    WTTTT    TTTE    FORCEPS 


543 


years  with  excellent  results.  After  careful  comparison  I  have 
chosen  for  my  own  use  the  Mat  hew  axis-traction  forceps.  The 
choice  in  this  part  of  Canada  lies  largely  between  Milne  Murray 
and  Porter  Mat  hew,  many  preferring  the  former. 

Description  of  the  Mikie  Murray  Axis-Traction  Forceps. — The 
application  handles  are  smooth  and  light  and  6  in.  in  length.  The 
ordinary  Smellie  lock  is  u.sed,  and  the  shanks  are  straight,  strong, 
2.5  in.  in  length  and  .75 
in.  between  their  inner  sur- 
faces. The  blades  are  5.75 
in.  in  length,  measured 
along  the  cord  of  the  pelvic 
curve  (this  arc  has  a  radius 
of  7  in.).  The  termination 
of  the  arc  joins  the  shanks, 
so  that  the  axis  of  the  in- 
struments and  the  cord  form 
of  the  blade  measures  1.75  in 


Fig.  200. — Lock  of  French  Forceps. 


an  angle  of  120°.  The  solid  part 
The  fenestrum  is  4  in.  in  length. 
The  blades  are  kept  in  position  by  a  fixation  screw  of  the  ordi- 
nary pattern,  the  butterfly-nut  being  prevented  from  coming  ofT 
by  a  pin  driven  through  the  upper  head  of  the  screw.  The  trac- 
tion-rods are  hinged  to  the  blades.     They  lie  on  the  outside  of 


Fig.    201.  —  Robe's 
Leg-Holder. 


the  solid  part  of  the  blade,  against  whidh  they  fit  snugly.  From 
their  attachment  the  rods  curve  round  the  blades,  and  are  bent 
at  an  angle  so  as  to  lie  straight  beside  and  a  little  to  the  outside 
of  the  shanks. 

One  inch  below  the  lock  they  are  bent  by  an  easy  curve  back- 
ward, and  terminate  in  two  flattened  surfaces,  in  which  are  inserted 
the  traction-handle  studs.     About  half-way  along  the  back  curve 

is  the  traction-rod  lock.     It  consists  of  a  pin  fixed  to  the  lower 
36 


544 


OBSTETEICAL    OPEEATIONS 


traction-rod  which  enters  a  mortise  on  the  upper,  in  which  it  is 
held  by  a  simple  bolt.  Its  object  is  to  bind  the  two  rods  into  one 
system  and  make  sure  that  the  force  of  traction  is  equally  dis- 
tributed on  the  two  blades. 

The  inclination  of  the  flattened  surfaces  terminating  the  rods 
and  carrying  the  traction-bar  studs  is  a  matter  of  essential  impor- 
tance. It  must  be  such 
that  the  traction-bar 
plate  when  attached 
must  be  absolutely  in 
the  tangential  line  of 
the  curve  when  the 
rods  are  touching  the 
shanks. 

The  distance  of  the 
studs  from  the  center 
of  the  handles  in  these 
instruments  is  3.5  in. 
The  studs  are  square 
in  section  with   large 
heads.     The  traction- 
bar  plate  is  attached 
by  a  couple   of   key- 
holes, and  when  drawn 
down  should  fit  firmly   without   to-and-fro  motion  of  any  sort. 
The  traction-handle  possesses  a  hinge- joint  giving  lateral  motion, 
and  the  bar  is  attached  by  a  swivel. 

The  traction-rods  are  jointed  to  the  blades,  and  run  down  close 
to  the  shanks  and  along  the  back  of  the  handles,  and  at  a  point 
half-way  down  they  then  turn  back  at  a  right  angle.  The  horizon- 
tal part  of  these  rods  is  oval  in  section,  and  the  upper  one  is  divided 
into  distances  half  an  inch  apart,  which  are  numbered  0  to  7. 

The  handle  is  applied  to  these  horizontal  rods  by  a  block 
pierced  to  allow  them  to  pass  through.  This  block  can  be  fixed 
in  any  position  by  a  pinching  screw,  which  is  secured  in  such  a 
way  that  it  cannot  slip  out.  To  this  block  is  fixed  the  handle  by 
a  joint  which  permits  motion  in  a  plane  parallel  to  the  rods.  This 
motion  is  necessary  to  allow  the  handle  to  fail  into  the  proper  line 
of  traction  for  each  position  on  the  rods. 

To  the  pin  of  the  hinge-joint  is  fixed  a  sector,  whick  moves 


Fig.  202. — Pajot's  maneuver  by  which  he  endeav- 
ors to  carry  out  the  axis-traction  principle  with 
the  ordinary  long  forceps  (Elliott's).  The  right 
hand  making  traction  on  the  handles.  Two 
fingers  of  the  left  hand  over  the  shanks  drawing 
backward. 


DELIVERY    WITH    THE    FORCEPS  545 

with  the  handle.  Th(>  periphiM-y  of  Ihe  sector  lias  iiiarke(l  on  it 
the  position  proper  to  it  for  each  i)osilion  of  the  block  on  the 
rods.  Against  one  of  these  marks  is  placed  the  word  "  normal." 
When  the  handle  is  adjusted  to  this  mark  the  iiislruincnt  is, 
as  regards  construction  and  efficiency,  an  ordinary  pair  of  axis- 
traction  forceps. 

To  adapt  them  to  a  pelvis  whose  inclination  is  less  than  normal, 
it  is  only  necessary  to  shift  the  block  one  or  more  divisions  nearer 
the  handle;  while  to  adapt  them  to  one  whose  inclination  is 
greater  than  normal,  the  block  must  be  moved  one  or  two  divisions 
farther  from  the  handle.  If  the  index  is  kept  at  the  figure  on  the 
section  corresponding  to  the  figure  at  which  the  block  is  set  on 
the  handle,  the  line  of  traction  will  always  pass  through  the  center 


Fig.  203. — Porter  Mathew  Forceps  Disarticulated  ;   Front  and  Back 
View  of  Blades. 

of  the  fenestrum ;  but,  of  course,  its  inclination  to  the  vertical  will 
vary  with  the  position  on  the  rods  at  which  the  handle  is  fixed. 

Dr.  Murray  has  another  forceps  which  is  older  and  better 
known  in  this  country  than  the  one  described  and  is  constructed 
for  the  normally  curved  pelvis.     In  it  the  traction-rods  are  not 


546 


OBSTETRICAL    OPEEATIONS 


rectangular,  but  slightly  curved,  and  end  in  two  flattened  spaces 
to  which  the  traction-handle  is  attached. 

Description  of  the  Porter  Mathew  Axis-Traction  Forceps. — 
The  forceps  are  made  entirely  of  metal  and  can  be  sterilized 
by  boiling.     The  traction-rods  are  detachable  and  easily  cleaned. 

The  weight,  especially  where 
undesirable,  has  been  di- 
minished as  much  as  is  con- 
sistent with  perfect  rigid- 
ity, the  diminution  being 
most  marked  in  the  appli- 
cation-handles, the  latter 
thereby  acting  the  more 
efficiently  as  true  indicators 
of  the  change  in  the  direc- 
tion of  the  descending  head. 
There  are  no  screws  or  fixed 
joints  except  to  those  parts 
outside  the  vulva,  and  such 
screws  as  are  present,  few 
in  number,  are  not  easily 
lost.  When  the  head  is  de- 
livered, it  is  only  necessary 
(without  touching  the  trac- 
tion apparatus)  to  give  a 
few  turns  to  the  large  screw 
on  the  handles,  when  the 
blades  slip  off  the  head. 

The  blades  have  a  pelvic 
curve  of  a  7-inch  radius; 
this  enables  a  good  grasp 
to  be  obtained  on  the  cor- 
rect plane  of  the  head.  They  are  stout  but  narrower  than  ordi- 
nary blades,  rendering  them  easy  of  introduction  and  manipula- 
tion, and  of  special  service  in  those  difficult  cases  of  flattened 
pelvis  when  the  head  lies  transversely  at  the  brim.  By  being 
narrow  they  grasp  only  the  occipital  and  frontal  bones,  avoiding 
the  parietals,  enabling  the  latter  to  mold  without  hindrance  in 
the  diameter  of  greatest  obstruction. 

The  lock  is  a  close-fitting,  ordinary  English  lock ;  a  model  has 


Fig.  204. 

articulated 


g     h 

Porter  Mathew  Forceps  Dis- 
SiDE  View  of  Blades. 


,  traction-rod;  6,  portion  of  traction-rod 
ho  which  traction-block  is  applied;  c,  han- 
dle of  blade;  d,  blade;  e,  fixation  screw;  /, 
butterfly-nut  of  fixation  screw;  g,  traction- 
block;  h,  catch  of  block  with  a  screw  and 
butterfl3^-nut ;  i,  traction-handle. 


DELIVERY    WITH    THE    FORCEPS 


547 


also  been  made  with  reversed  lock.     The  closo-fitting  lock  insures 
the  blados  when  locked,  being  properly  adapted  to  the  head. 

The  application  handles  have  been  nuich  shortened  and  light- 
ened. Once  the  blades  are  applied  the  handles  become  merely 
"indicators"  and  are  not  designed  for  traction.  Owing  to  their 
lightness  they  do  not  "  fall  downward,"  and  the  slightest  move- 
ment of  the  head  is  communicated  to  them;  being  so  delicate  a 
guide,  to  insure  proper  axis-traction  throughout  the  operator  has 
merely  to  pull,  keeping  the 
traction-rods  constantly  par- 
allel and  close  to  the  applica- 
tion handles  as  the  latter 
move  forward  with  descent. 
Another  great  advantage  of 
the  short  handle  is,  that  on 
locking  the  forceps  the  second 
traction-rod  falls  into  posi- 
tion without  having  to  be 
carried  far  forward  to  clear  a 
long  application  handle.  An 
objection  that  the  short  han- 
dle would  upset  the  balance 
of  the  blade  and  make  it  diffi- 
cult of  introduction  with  the 
head  high  up,  has  been  found 
to  be  purely  theoretical  even 
above  the  brim,  for  in  intro- 
duction the  traction-rod  and 
handle  are  grasped  together, 
and  will  be  found  to  give  a 
comfortable  and  convenient 
hold,  the  left  blade  being 
passed  with  its  traction-rod 
behind  the  handle,  the  right 
blade  with  its  rod  just  in 
front  of  the  handle.  On  locking,  the  second  traction-rod  slips 
backward  into  position  beside  the  first  traction-rod. 

The  traction-rods  are  the  well-known  rectangular  ones  of  Dr. 
Milne  Murray.  The  forceps  are  thus  true  for  all  pelves,  instead 
of  being  true  only  for  a  normal  pelvis.     By  an  ingenious  contri- 


FiG.  205. — Porter  Matiiew  Forceps 
Articulated. 

Catch  of  block  underneath  and  closed  in 
fourth  notch  of  traction-rod,  fixation 
screw  fastened  at  end  of  handles. 


548 


OBSTETRICAL    OPERATIONS 


vance,  copied  from  Dr.  Cullingworth's  forceps,  the  rods  are  easily 
detachable  by  an  aseptic  joint,  the  old  objectionable  screws  being 
done  away  with. 

The  traction-block.  Much  time  and  care  have  been  expended 
by  Messrs.  Down  Bros,  (who  have  made  the  forceps)  in  designing 
a  new  form  of  traction-block  which  should  be  mathematically 
and  mechanically  correct,  and  yet  have  the  advantage  of  sim- 
plicity, lightness,  ease,  and  rapidity  of  application  and  admit  of 

being  easily  cleansed.  The 
great  difficulty  has  been  to 
avoid  screws,  which  might  be 
lost  and  make  the  instrument 
temporarily  useless.  To  in- 
sure asepsis  it  can  be  boiled. 
One  movement  fixes  the  block 
and  rods  securely. 

The  line  of  traction  has 
been  calculated  by  "shadow 
projection,"  the  ray  of  light 
being  kept  perpendicular  to 
the  blade ;  very  accurate  results 
are  obtained  by  this  means. 

The  two  instruments  are 
much  alike.  The  Porter  Math- 
ew  is  simply  a  modification  of 
the  Milne  Murray,  but  it  is  smaller  and  lighter;  its  blades  have 
a  slightly  different  cephalic  curve  and  are  more  easily  applied, 
and  its  traction-rods  are  more  easily  got  into  position  for  the 
attachment  of  the  traction-handle. 

Some  of  the  advantages  of  the  axis-traction  forceps  may  be 
cited,  quoting  largely  from  Milne  Murray.  The  great  advantage 
of  its  use  at  the  brim  is  generally  understood  and  admitted.  In 
many  cases  the  axis-traction  instrument  will  accomplish  what  the 
ordinary  long  forceps  cannot  do.  "  For  once  they  have  proved 
their  efficacy  at  the  brim,  they  have  done  so  ten  times  in  the  cavity 
and  twenty  times  at  the  outlet."  The  blades  grasp  the  head 
securely  without  producing  dangerous  compression.  Extraction 
is  accomplished  with  comparative  ease  and  without  any  waste  of 
force.  It  is  necessary  only  to  preserve  the  proper  relationship 
between    the    traction-rods    and   the   shanks.     By  keeping  the 


Fig.  206. — Porter  Mathew  Forceps. 

Blades  and  traction-rod  held  in  hands 

before  application. 


DELTVEin'    WITH    THE    FOI^fEPS 


549 


instrument  on  the  head  until  deli  very  there  will  generally  be  less 
injury  to  the  pelvic  floor  and  tiie  perinoiUm.  At  no  stage  will  the 
instrument  prevent  flexion  and  rotation  of  the  child's  head. 

Application  of  the  Murray  Forceps. — The  blades  are  joined  with 
concavity  of  j)el\-ic  curve  forward.  The  handle  of  the  left  blade 
is  taken  in  the  left  hand.  The  handle  is  held  in  the  full  hand  with 
the  thumb  lying  on  its  inner  surface  while  the  other  fingers  are 
distributed  over  the  outer  surface  near  the  lock.  The  fingers  of 
the  right  hand  are  placed  in  the  vagina  with  tips  between  cervix  and 
the  child's  head.  The  blade  is  passed  along  palmar  aspect  of 
fingers  toward  the  sacrum  or  slightly  toward  the  left  side  of  the 
pelvis,  the  handle  being  held  well  upward.  As  the  tip  of  the 
blade  enters  the  handle  is  brought  downward  along  the  internal 
surface  of  the  mother's  right  thigh,  and  the  blade  is  brought 
toward  the  side  of  the 
pelvis.  While  introducing 
the  left  blade  the  traction- 
rod  is  allowed  to  remain 
below  (hanging  down- 
ward). The  shank  of  the 
blade  wall  now  pass  against 
the  perinaeum.  The  handle 
is  kept  steady  with  the 
wrist,  or  an  assistant  holds 
it.  The  handle  of  the  re- 
maining blade  is  taken  in 
the  right  hand.  The  axis- 
traction  is  kept  upward 
out  of  the  way.  The  fin- 
gers of  the  left  hand  are 
placed  in  the  vagina,  and 
the  right  blade  is  intro- 
duced as  in  the  case  of  the 
left  blade.  If  a  pain  comes  on  during  the  application  of  a  blade, 
manipulations  cease  until  the  pain  has  passed  off.  The  handles 
are  taken  in  the  two  hands,  the  blades  adjusted  and  locked,  and 
the  screw  is  fastened.  One  traction-rod  is  now  below  and  the  other 
above.  The  latter  is  pulled  down  beside  and  below  the  locked 
blades.  The  two  traction-rods  are  now  below  the  application  han- 
dles.    The  traction-handle  is  attached  to  the  two  traction-rods. 


Fig.  207. — Application  of  First  Blade. 
Porter  Mathew  Forceps. 


550 


OBSTETEICAL    OPERATIONS 


Application  of  Porter  Mathew  Forceps. — The  traction-block 
and  handle  are  laid  aside  at  first,  but  the  blades  are  applied  with 
the  traction-rods  in  place.  The  patient  is  in  the  dorsal  position. 
The  left  blade  is  taken  in  the  left  hand,  the  thumb  in  the  angle  of 

the  traction-rod,  and  the 
fingers  encircling  the  trac- 
tion-rod and  handle  and 
keeping  them  close  togeth- 
er. The  fingers  of  the 
right  hand  are  introduced 
into  the  vagina  and  the 
blade  applied  along  their 
palmar  surface  as  in  the 
Murray  forceps  applica- 
tion. The  handle  of  this 
blade  being  kept  back  out 
of  the  way  by  an  assistant, 
the  right  blade  is  grasped 
in  the  right  hand,  as  fol- 
lows :  The  traction-rod  is 
carried  far  enough  forward 
to  bring  it  in  front  of  its 
handle,  the  fingers  encir- 
cling the  handle ;  the  but- 
terfly-nut of  the  fixation-screw  is  run  out  to  the  end  of  its  screw, 
and  the  screw  itself  turned  out,  away  from  the  traction-rod,  and 
allowed  to  project  between  the  first  and  second  fingers ;  the  traction- 
rod  is  kept  in  position  by  gentle  pressure  with  the  thumb  on  the 
outer  side  of  its  angle ;  the  rectangular  part  of  the  rod  projects  back- 
ward between  the  thumb  and  the  fingers.  Grasping  the  blade  thus, 
it  is  applied  like  the  second  blade  of  the  Murray  forceps ;  as  the  lock 
is  closed  the  traction-rod  falls  easily  back  into  position  behind  its 
handle.  The  fixation  screw  is  then  turned  into  its  place  and  the 
nut  screwed  home,  not  tightly,  but  just  enough  to  keep  the  handles 
as  closely  together  as  they  can  be  brought  by  gentle  pressure  with 
the  hands.  Then  take  the  traction-block,  open  its  catch  widely 
and  run  the  butterfly-nut  out  to  the  end  of  its  screw.  Then  slip 
the  block  on  to  the  rods,  taking  care  that  the  catch  is  on  the  side 
next  to  the  notches  in  them.  Slip  it  up  the  rods  until  three  notches 
are  passed  and  close  the  catch  into  the  fourth  notch,  which  is  the 


Fig.  208. — Application  of  Second  Blade. 
Porter  Mathew  Forceps. 


DELIVERY  WITH  THE  FORCEPS 


351 


position  for  normal  pelves,  and  screw  the  nut  home.  For  flat 
pelves  the  block  is  fixed  in  the  fifth,  sixth,  or  seventh  notch, 
accordino;  to  circumstances — i.  e.,  traction  is  made  in  each  notch 
until  that  notch  is  found  in  which  the  liead  comes  most  readily. 
For  "small  round  pelves  "  the  block  is  fixed  similarly  at  third  or 
second.  The  handle  is  then  hooked  over  the  bar  provided  for  that 
purpose,  not  over  the  catch. 

Traction  is  made  keeping  the  traction-rods  just  parallel  to  the 
hantlles,  not  pushing  against  them  nor  widely  separated  from 
them.  All  traction  must  be  made  with  the  traction-handle,  neither 
the  traction-rods  nor  the  handles  of  the  blades  being  touched. 
As  the  head  comes  down  the  handles  will  be  found  to  turn  upward 
and  forward.  This  indicates  the  direction  in  which  traction  is  to 
be  made,  and  each  change  in  position  must  therefore  be  closely 
followed  by  the  traction-rods. 

In  removing  the  forceps  the  traction-block  and  handle  are 
first  removed.  The  fixation  screw  is  then  undone  and  turned 
outward.  The  right  traction-rod  is  then  carried  in  front  of  its 
handle  and  the  right 
blade  removed  in  the 
reverse  direction  of  its 
application.  The  left 
blade  is  then  similarly 
removed,  except  that 
its  traction-rod  does 
not  need  to  be  carried 
forward. 

When  using  the 
ordinary  long  or  short 
forceps  introduce  the 
blades  and  lock  as 
described  for  the  ap- 
plication of  the  Murray  forceps.  This  is  illustrated  by  cuts  show- 
ing what  Williams  calls  low  forceps  introduction  (Figs.  210  to  213). 

How  shall  the  Blades  be  Applied?— According  to  many  author- 
ities in  Great  Britain  and  Germany,  our  aim  should  be  to  so  apply 
the  blades  that  they  will  be  parallel  to  the  sides  of  the  mother's 
pelvis.  Many  obstetricians  in  France  and  America  endeavor  to 
apply  the  blades  to  the  sides  of  the  child's  head  without  regard  to 
the  sides   of  the   pelvis.     The   differences   of  opinion  in   certain 


Fig.  209. — Blades  Locked  and  Traction-Handle 
APPLIED.     Porter  Mathew  Forceps. 


552  OBSTETEICAL    OPEEATIONS 

communities  are  very  decided.  Take  the  University  of  Edin- 
burgh, for  instance,  where  we  find  the  extra-mural  differing  from 
the  intra-mural  teacher.     The  one  tells  us  that  it  is  largely  the 

teaching  and  the  practice 
of  the  British  schools  to 
apply  the  forceps  as  far  as 
possible  in  relation  to  the 
pelvic  transverse  without 
reference  to  the  position  of 
the  head.  He  at  the  same 
time  expresses  a  positive 
opinion  that  this  is  wrong 
when  the  head  is  not  prop- 
erly rotated.  The  result  of 
this  practice  is  to  obtain  an 
oblique  grasp  of  the  head, 
which  causes  difficulties  in 
locking  and  certain  dangers. 
Even  though  locking  be  ac- 
complished without  injury, 
the  head  as  it  descends 
rotates,  causing  the  edges 
of  the  blades,  if  there  is  no 
^      „,„     ^  ,        „  removal  and  readiustment, 

riG.  210. — Introduction  of  Left  Blade. 

Ordinary  Long  Forceps  (Williams).  to  do  mUch  damage   to   the 

outlet.  Or  the  head  de- 
scends without  rotating  and  engages  the  outlet  in  the  oblique  with 
results  still  more  disastrous.  An  author  representing  the  other 
side  of  Edinburgh  tells  us  that  the  long  forceps  are  always  applied 
laterally  as  to  the  pelvis,  no  regard  being  paid  to  their  grasp  of 
the  head.  Clarence  Webster,  another  Edinburgh  man,  considers 
the  French  method  unscientific,  ridiculous,  and  dangerous. 

Dr.  Murray  prefers  the  French  method,  and  advises  us  to 
apply  the  blades  to  the  biparietal  diameter  of  the  child's  head 
wherever  situated.  As  the  head  descends  rotation  brings  the 
blades  into  the  transverse  diameter  when  the  occiput  comes  to  the 
front.  The  application  of  the  blades  to  the  sides  of  the  head 
requires  more  care,  but  it  is  our  duty  to  take  what  care  is  neces- 
sary for  the  benefit  of  the  patient.  There  is  nothing  new  in  these 
allegations,  nor  have  I  any  doubt  that  they  are  correct.     Not- 


DELIA' FJJV    Wrril    T\\\']    FORCEPS 


553 


withstanding  my  admiration  for  the  I^'reiich  iiuMhod,  however,  I 
have  for  years  hesitated  about  recommencUng  it  universally  to  my 
classes,  nor  am  I  prei)ared  to  do  so  now. 

Why  not  adopt  the  French  method  in  all  eases?  l^ecause  it 
requires  more  skill  than  the  average  obstetrician  can  acquire  in  a 
hfctime  to  accomplish  it  safely  in  a  large  proportion  of  cases. 
Strenuous  efforts  to  apply  the  blades  to  the  parietal  diameter  of 
the  head  in  difhcult  cases  are  dangerous  to  both  mother  and  child. 
A  large  proportion  of  obstetricians  are  convinced  that  theoretically 
the  French  method  is  excellent,  but  practically  it  is  often  danger- 
ous and  even  impossible.  At  least  such  is  my  experience,  and  I 
have  been  endeavoring  to  carry  out  the  French  method  for  fifteen 
years. 

The  following  rules  are  recommended :  One  should  try  to 
ascertain  the  exact  position  of  the  child's  head,  and  endeavor  to 
apply  the  blades  to  the  sides 
of  the  head  without  regard 
to  the  sides  of  the  pelvis — 
i.  e.,  make  an  effort  to  em- 
ploy the  French  method.  If 
unable  to  accomplish  this, 
apply  the  blades  laterally 
as  to  the  pelvis,  but  do  not 
drag  the  head  far  before  re- 
moving and  readjusting  the 
blades.  It  is  comparatively 
easy  in  certain  cases  to  apply 
the  blades  to  the  sides  of  the 
head.  If,  for  instance,  the 
head  is  in  the  cavity  of  the 
pelvis  with  the  occiput  to- 
ward the  left  front,  one  has 
only  to  introduce  the  blades 
so  that  the  left  blade  will 
be  slightly  behind  on  the  left 

side  and  the  right  blade  slightly  forward  on  the  right  side, 
times  one  can  scarcely  avoid  doing  this. 

Traction. — Seize  the  handle  Avhich  is  attached  to  the  traction- 
rods  with  the  one  hand,  and  while  pulling  see  that  the  rods  and 
shanks  are  kept  just  touching,  or  almost  touching  each  other. 


r"iG.  211. — Left  Blade  in  Place. 
Ordinary  Long  Forceps  (Williams). 


Some- 


554 


OBSTETEICAL    OPERATIONS 


While  thus  extracting  the  child  one  will  find  that  the  traction  is 
exerted  exactly  in  the  right  direction  at  all  times  as  the  head 
passes  through  the  pelvis  and  emerges  from  the  vulva ;  flexion  will 

be  properly  maintained, 
and  when  incomplete 
will  frequently  be  pro- 
moted ;  rotation  will  be 
allowed;  the  head  will 
so  far  as  possible  be 
prevented  from  bearing 
too  heavily  on  the  pel- 
vic floor;  the  head  will 
be  lifted  over  the  peri- 
naeum ;  and  as  the  head 
is  brought  through  the 
vulva  it  will  not  be  ex- 
tended so  as  to  cause 
the  chin  to  cut  through 
the  perinseum. 

In  using  traction  do 
not  attempt  to  extract 
rapidly.  It  was  before 
stated  that  during  nor- 
mal labor,  after  the 
vault  of  the  head  reach- 
es the  pelvic  floor,  its 
expulsion  from  the  vul- 
va should  occupy  at 
least  "from  twenty  to 
thirty  minutes.  Extraction  with  the  forceps  should  occupy  no 
less  time.  Pull  gently  on  the  handle,  as  far  as  possible  during 
pains,  and  desist  during  the  intervals  between  them.  If  unable 
to  detect  uterine  contractions,  pull  inteimittently.  Endeavor  to 
extract  with  the  smallest  amount  of  force.  Use  one  hand  at  first ; 
this  will  generally  be  sufficient.  In  exceptional  cases  it  will  not, 
and  then  one  will  require  more  force  and  may  use  two  hands. 

As  soon  as  the  head  reaches  the  pelvic  floor  one  should  con- 
sider the  danger  of  injury  to  that  structure  and  the  perinseum. 
It  was  stated  in  connection  with  normal  labor  that  when  the 
thighs  are  flexed  on  the  body  a  tightening  of  the  skin  around  the 


Fig.  212. — Introduction  of  Right  Blade. 
Ordinary  Long  Forceps  (Williams). 


DELIVERY   WITH    THE    FORCEPS 


555 


vulva  occurs.  The  patient  is  directed  to  extend  the  legs  and 
thighs  in  order  to  slacken  this  tension.  Tliis  tightening  is  still 
more  apt  to  occur  when  the  thighs  are  fastened  in  the  flexed  posi- 
tion with  sonic  form  of  leg-holder.  It  is  extremely  important, 
therefore,  to  observe  the  following  rule: 

As  soon  as  the  head  commences  to  ])ress  on  the  pelvic  floor 
observe  the  time,  remove  the  leg-holder,  and  allow  extension  of 
the  thighs — i.  c.,  allow  the  legs  and  thighs  to  hang  over  the  edge 
of  the  bed  or  over  the  end  of  the  operating  table  toward  the  floor. 
In  an  ordinary  bed  the  patient's  feet  may  rest  on  the  floor  while 
the  nurse  keeps  the  thighs  separated  by  holding  the  knees  out- 
ward. 

Do  not  employ  less  than  twenty  to  thirty  minutes  in  extracting 
the  head  after  it  has  reached  the  pelvic  floor.  I  attach  a  great 
deal  of  importance  to  this  rule.  It  is  very  desirable  that  the 
operator  take  his  time 
from  a  watch  or  clock  and 
not  trust  to  guess-work. 
Twenty  to  thirty  minutes 
will  appear  a  long  time, 
especially  if  one  has  seen 
some  strenuous  and  mus- 
cular operator  drag  the 
head  over  the  pelvic  floor 
and  through  the  vulva  in 
about  a  minute.  In  order 
to  do  so,  however,  he  may 
require  to  use  a  force  of 
one  or  two  hundred 
pounds,  while  the  safe 
operator  by  a  slower  and 
less  brilliant  method  may 
only  require  to  use  a  force 
of  one  to  ten  pounds.  The 
former  will  probably  pro- 
vide some  material  for  the  gynaecologist,  while  the  latter  will  lift 
the  head  over  the  pelvic  floor  and  through  the  vulva  without  in- 
flicting any  injury.  While  pulling  gently  and  intermittently  for 
fifteen  to  twenty-five  minutes,  the  anaesthetic  may  be  withheld  to 
some  extent,  but  it  should  be  freely  administered  while  the  head 


Fig.  218. — Fcjrceps  Locked. 
Ordinary  Long  Forcepi  (Williams). 


556 


OBSTETEICAL    OPEEATIONS 


is  emerging  from  the  vulva.  Occasionally  the  utenne  contrac- 
tions assist  expulsion  while  the  head  is  pressing  on  the  pelvic 
floor,  and  expedite  delivery.  If  Nature's  efforts  should  suddenly 
become  violent,  have  the  anaesthetic  freely  administered,  leave  the 
forceps  in  position,  and  guide  the  passage  of  the  head  so  as  to 
make  it  ghde  over  rather  than  cut  into  the  pelvic  floor.  While 
exerting  slight  traction  on  the  cross-bar  with  the  one  hand  to 


Fig.  214. — Walcher's  Position 

pull  the  head  toward  the  pubic  arch,  it  is  sometimes  advisable 
to  push  against  the  advancing  head  with  the  fingers  of  the  other 
hand  to  prevent  too  rapid  expulsion. 

While  Milne  Murray  generally  employs  traction  during  the 
pains,  he  refers  to  one  group  of  cases  where  a  different  plan  should 
be  adopted.  It  sometimes  happens,  especially  in  elderly  primip- 
arae,  that  every  uterine  contraction  when  the  head  is  low  is  ac- 
companied by  spasmodic  action  of  the  muscles  of  the  pelvic  floor, 
which  narrows  or  tightens  the  vulvar  orifice  and  causes  rigidity 


DELIVERY    WITH    TTTE    FOKOEPS  557 

of  the  pelvic  floor  and  perinaeum.  In  such  a  case  deepen  the 
ana3sthesia  and  employ  traction  only  during  the  intervals  between 
th6  pains. 

As  before  intimated,  in  the  majority  of  cases  in  the  high  and 
middle  operations  the  blades  will  generally  grasp  the  head  oblique- 
ly. It  is  not  safe  to  drag  the  head  far  before  removing  and  re- 
adjusting the  blades.  The  following  rules  are  recommended :  As 
soon  as  the  position  of  the  blades  shows  that  rotation  of  the  head 
has  commenced,  remove  the  blades,  reintroduce  and  readjust  them. 
Otherwise  do  not  remove  the  forceps  until  after  complete  deliv- 
ery of  the  head.  During  the  delivery  of  the  head,  even  while  it  is 
passing  over  the  perinseum,  continue  to  pull  on  the  cross-bar  with- 
out regard  to  the  application  handles.  Many,  if  not  most,  ob- 
stetrical authorities  in  the  United  States  only  use  the  traction  in 
high  and  middle  operations,  and  some  only  use  them  in  the  high 
operations.  Some  authorities,  both  in  Great  Britain  and  the 
United  States,  relax  the  fixation  screw  during  the  interval  be- 
tween making  traction.  This  is  unnecessary  when  using  either 
the  Murray  or  Mathew  forceps,  because  (as  mentioned  before)  the 
blades  grasp  the  head  securely  without  producing  dangerous  com- 
pression, and  the  compression  is  not  increased  during  traction  as 
it  is  when  using  the  ordinary  short  or  long  forceps. 

If  the  old  forceps  without  the  traction-rods  and  cross-bar  are 
used,  apply  and  lock  as  described  for  Milne  Murray's  instrument. 
If  the  head  is  high  in  the  pelvis,  pull  first  downward  and  back- 
ward. As  the  head  descends  bring  the  handles  gradually  toward 
the  front — i.  e.,  toward  the  mother's  abdomen.  Be  careful,  how- 
ever, not  to  bring  the  handles  too  far  forward  while  the  head  is 
emerging — i.  e.,  do  not  extend  the  head  so  much  that  the  chin 
cuts  through  the  perinseum.  If  the  old  long  forceps  is  preferred, 
it  is  well  to  select  the  Simpson  or  ElHot  instrument. 

Anaesthesia. — Operative  interference  adds  a  new  element  to 
labor.  It  was  stated  before  that  an  anaesthetic  might  be  admin- 
istered in  two  different  ways:  (1)  to  the  obstetrical  degree;  (2)  to 
the  surgical  degree — the  obstetrical  degree  being  generally  suffi- 
cient in  normal  labor,  the  surgical  degree  being  generally  neces- 
sary for  operative  procedures.  We  may  consider  that  the  latter 
rule  applies  to  forceps  delivery,  although  not  for  the  same  reasons 
which  prevail  in  other  operations.  The  appHcation  of  the  blades 
of  the  forceps  and  traction   during  uterine   contractions   causes 


558  OBSTETRICAL    OPEEATIONS 

little  or  no  extra  pain.  We  want  profound  anaesthesia,  not  espe- 
cially to  prevent  pain,  but  to  keep  the  patient  quiet  during  our 
manipulation.  The  violent  movements  of  semi-intoxication  may 
cause  serious  injuries.  One  should  therefore  do  one  of  two  things : 
(1)  administer  no  anaesthetic.  This  may  cause  surprise  to  those 
who  have  seen  anaesthetics  administered  as  a  matter  of  routine 
practice  in  maternity  hospitals.  Our  custom  generally  in  Toronto 
is  to  administer  the  anaesthetic.  The  country  practitioner,  how- 
ever, will  often  choose  to  use  the  forceps  without  anaesthesia, 
especially  when  miles  away  from  a  brother  physician.  (2)  Get  an 
assistant  to  completely  anaesthetize  the  patient,  especially  during 
the  application  of  the  blades  and  the  delivery  of  the  head  through 
the  vulva,  as  already  mentioned.  Surgeons  generally  observe  a 
good  rule  in  making  the  administration  of  anaesthetics  the  work 
of  one  man  who  shall  assume  full  responsibility.  Obstetricians 
would  do  well  to  adopt  the  same  rule,  which  is  really  the  only 
safe  one.  Many  practitioners,  however,  allow  the  nurse  to  give 
the  anaesthetic.  Although  they  direct  the  nurse  and  watch  the 
patient  as  carefully  as  possible,  such  practice  involves  a  certain 
amount  of  risk,  which  may  occasionally  be  considerable. 


CHAPTER  XXVI 
MAJOR   OBSTETRICAL   OPERATIONS 

Caesarean  Section. — This  is  the  removal  of  the  child  from  the 
uterus  by  an  incision  through  the  abdominal  and  uterine  walls. 
It  is  indicated  when  abdominal  section  is  the  only  method  by 
which  the  child  can  be  delivered  ;  for  example,  when  the  con- 
jugate diameter  in  a  generally  contracted  pelvis  measures  only 
2h  inches;  when  tumors  or  cicatrization  in  the  pelvis  prevent 
delivery;  when,  after  the  death  of  the  mother,  the  child  can  be 
delivered  more  quickly  by  section  than  in  any  other  way.  It  is 
also  indicated  in  certain  cases  of  rupture  of  the  uterus,  severe 
accidental  haemorrhage,  etc.  Some  operate  about  the  end  of 
pregnane}',  but  before  labor  begins,  while  others  prefer  to  wait 
until  labor  has  commenced. 

Operation.  The  instruments  required  are  a  sharp  knife,  scis- 
sors, needles  and  needle-holder,  dissecting  forceps,  artery  forceps 
(12  pairs),  towels,  gauze,  ligatures,  and  sponges.  Six  assistants 
are  reciuired:  one  to  give  the  anaesthetic,  one  to  assist  in  lifting  out 
the  uterus,  one  to  compress  the  cervix,  one  to  take  charge  of  the 
child,  and  two  to  take  care  of  sponges,  irrigating  apparatus,  etc. 
The  latter  two  may  be  nurses.  The  patient  is  prepared  as  for  an 
ordinary  laparotomy,  the  bowels  and  bladder  are  emptied,  sub- 
umbilical  region  shaved,  and  all  the  parts,  including  the  vagina, 
thoroughly  cleansed  with  antiseptics,  etc. 

The  abdominal  incision  is  made  in  the  middle  line  one-third 
above  and  two-thirds  below,  or  half  above  and  half  below  the 
umbilicus.  The  assistant,  after  the  uterus  is  exposed,  presses  the 
abdominal  walls  against  it,  and  the  uterine  incision,  15-18  cm. 
long  (6-7  inches),  is  made  in  the  median  line  commencing  at  a 
point  just  below  the  fundus  and  running  toward  the  cervix. 
Some  make  the  abdominal  incisions  long  enough  to  allow  the 
uterus  to  be  turned  out  before  opening  it.  The  amnion  is  rup- 
tured, the  breech  or  one  foot  or  both  seized,  and  the  child  extracted 
as  rapidly  as  possible.  If  the  placenta  lies  in  the  line  of  incision, 
37  559 


560  MAJOE  OBSTETEICAL    OPERATIONS 

the  fingers  should  be  passed  between  it  and  the  uterine  wall  to  its 
margin,  where  the  membranes  should  be  ruptured  and  the  feet 
grasped  as  before  described.  In  delivering  the  child  the  head 
should  be  well  flexed.  The  cord  should  be  clamped  by  two  artery 
forceps  and  then  divided  between  them.  The  placenta  and  mem- 
branes should  then  be  removed.  If  there  is  excessive  haemorrhage 
at  any  stage,  an  assistant  should  grasp  the  neck  of  the  uterus  with 
both  hands  and  make  firm  pressure  until  the  deep  sutures  are 
introduced.  The  sutures  should  be  placed  in  two  layers,  deep  and 
superficial  (Kelly).  The  deep  sutures,  two  or  three  to  the  inch, 
pass  through  the  entire  thickness  of  the  uterine  wall  down  to  the 
decidua.  Twice  as  many  sutures  of  fine  silk  are  introduced 
through  the  peritonaeum  on  either  side  of  the  incision.  Some  use 
half  deep  sutures  after  the  deep  ones  are  tied,  but  before  the  super- 
ficial ones  are  introduced.  The  abdominal  wound  is  closed  in  the 
ordinary  way.  (Some  prefer  a  transverse  incision  through  the 
fundus  (Fritsch).  The  after-treatment  is  the  same  as  that  for 
any  laparotomy. 

Vaginal  Caesarean  Section. — Dlihrssen  advises  vaginal  Csesarean 
section  where  rapid  delivery  is  indicated.  A  circular  incision  is 
made  through  the  mucosa  covering  the  cervix  close  to  the  fornix 
and  extending  into  each  lateral  fornix  half  an  inch.  The  mucosa 
flap  is  stripped  upward  with  the  bladder,  and  the  cervix  pulled 
down  by  means  of  a  volsella.  The  bladder  is  held  up  out  of  danger 
by  a  retractor  and  the  cervix  divided  anteriorly  and  posteriorly 
in  the  middle  line.  The  anterior  incision  is  extended  four  or  five 
inches  up  the  uterine  wall,  but  not  through  the  peritonaeum.  The 
child  is  extracted  through  the  incision  and  the  placenta  and  mem- 
branes removed.  The  uterus  is  plugged  with  iodoform  gauze  and 
the  incisions  closed  with  catgut. 

Porro's  Operation. — This  is  the  supravaginal  amputation  of 
the  uterus  after  a  Caesarean  section.  It  is  indicated  where  the 
uterine  tissues  have  been  seriously  injured  by  attempts  at  deliv- 
ery; where  the  child  is  putrid  or  where  there  is  septicaemia;  where 
there  are  extensive  adhesions  and  cicatrices  in  the  vault  of  the 
vagina ;  where  fibroids  of  the  uterus  exist ;  where,  after  abdominal 
section  for  ruptured  uterus,  the  tear  is  found  to  be  very  ragged 
and  to  involve  other  structures,  or  if  the  haemorrhage  cannot  be 
arrested;  where,  for-  sufficient  reason,  there  is  a  desire  to  avoid 
future  pregnancies. 


SYMPIIYSTOTOMY  561 

Operaiinn.  The  technique  for  this  operation  is  the  same  as 
that  for  Ca^sarean  section  up  to  the  point  where  the  child  is  deliv- 
(>r('(l.  Then  the  placenta  and  iiienibranes  should  be  left  in  the 
uterus  and  an  elastic;  li<!;ature,  loosely  tied,  passed  around  the 
lower  uterin{>  segment.  To  prevent  the  abdominal  cavity  being 
contaminated  by  uterine  fluids,  a  small  opening  in  a  large  rubber 
sheet  is  passed  over  the  fundus  down  to  the  elastic  ligature.  This 
ligature  is  then  drawn  tight  by  the  assistant  and  the  uterus  ampu- 
tated f  inch  above  it.  The  stump  is  disinfected  and  cauterized 
and  may  then  be  treated  i,n  one  of  two  ways:  (1)  extraperi- 
toneal, or  (2)  intraperitoneal. 

In  the  extraperitoneal  treatment  the  stump  is  encircled  with 
a  loop  of  a  Koeberle's  ecraseur  just  below  the  rubber  tubing  and 
the  ecraseur  drawn  tight,  care  being  taken  not  to  include  the  wall 
of  the  bladder.  The  rubber  tubing  is  then  removed  and  two  long 
needles  passed  through  the  stump  above  the  wire  loop.  The 
abdominal  wound  is  then  sutured.  The  stump  is  brushed  with  a 
solution  of  the  perchloride  of  iron ;  if  haemorrhage  recurs  the  wire 
may  be  tightened.  The  needles  are  removed  in  from  ten  to  twelve 
days.  In  the  intraperitoneal  treatment  the  mucous  membrane 
is  sutured  first,  then  over  this  the  muscular  tissue,  and  over  it  the 
serous  membrane.  The  rubber  tubing  is  then  removed,  any  haem- 
orrhage controlled  by  ligatures,  and  the  pedicle  dropped  into  the 
abdominal  cavity.  Or  the  stump  may  be  treated  as  that  in  an 
ordinary  myomectomy,  a  description  of  which  will  be  found  in 
any  text-book  on  gyna?cology.  * 

Total  Abdominal  Hysterectomy. — Occasionalh'^  in  some  cases 
it  is  advisable  to  remove  the  whole  uterus,  especially  where  there 
is  malignant  disease  or  a  very  bad  rupture.  This  operation  is 
described  in  text-books  on  gynaecology. 

S5miphysiotomy. — This  is  the  operation  of  cutting  through 
the  symphysis  pubis  for  the  purpose  of  increasing  all,  but  espe- 
cially the  transverse,  diameters  of  the  pelvis.  It  is  indicated 
where  the  pelvis  is  so  small  or  deformed  as  to  prevent  delivery  by 
version  or  forceps,  but  at  the  same  time  large  enough  with  the 
increase  in  size  attained  by  the  operation  to  allow  the  delivery 
of  a  living  child.  It  occupies,  therefore,  a  position  between  ver- 
sion and  forceps  on  the  one  hand,  and  embryotomy  and  abdominal 
section  on  the  other.  The  range  of  operation  lies  between  conju- 
gate diameters  of  3;^  and  2f  inches  in  a  pelvis  otherwise  normal. 


562  MAJOE  OBSTETEICAL    OPERi^TIONS 

Greater  conjugate  diameters  are  required  in  a  pelvis  otherwise 
generally  contracted. 

Operation.  The  following  instruments  are  required :  a  scalpel, 
a  probe-pointed  curved  bistoury  (or  a  Galbiani  or  Morrison  knife), 
two  or  more  haemostatic  forceps,  needles  and  needle-holder,  a 
metallic  catheter  or  vulcanite  rod,  strips  of  iodoform  gauze,  silk 
or  wire  sutures,  strips  of  adhesive  plaster,  antiseptic  cotton,  a 
strong  abdominal  binder,  obstetric  forceps,  and  a  Clover's  crutch. 
Four  assistants  are  required,  one  to  give  the  anaesthetic,  one  to 
hold  the  catheter  in  the  urethra,  one  to  secure  uterine  contraction 
and  to  express  the  placenta,  and  one,  a  nurse,  to  take  charge  of 
the  child. 

Italian  or  Subcutaneous  Method. — The  genitaha  are  carefully 
washed  with  an  antiseptic  solution,  the  mons  veneris  shaved,  and 
the  bowels  and  bladder  emptied.  The  patient  is  placed  in  the 
lithotomy  position  with  a  Clover's  crutch.  The  catheter  or  vulcan- 
ite rod  is  introduced  into  the  urethra  and  depressed  from  the 
pubic  arch  and  pushed  over  to  the  right  side.  A  median  incision 
2  inches  long  is  made,  extending  to  or  a  little  below  the  top  of  the 
symphysis,  deep  enough  to  reach  the  sheath  of  the  rectus  muscle 
and  the  joint.  Any  haemorrhage  is  arrested  and  small  transverse 
incisions  are  made  into  the  pyramidalis  muscle  on  either  side  to 
make  room  for  the  finger.  The  left  index  finger  is  then  introduced 
behind  the  symphysis  down  to  its  lower  border,  the  urethra  located 
where  it  has  been  depressed  and  pushed  to  the  right  by  the  catheter 
(or  rod).  This  being  out  of  the  field  of  operation,  the  probe- 
pointed  bistoury  (or  special  knife)  is  introduced  along  the  finger 
to  the  lower  border  of  the  symphysis.  The  subpubic  ligament  is 
then  cut  and  also  the  symphysis  from  below  upward  and  from 
behind  forward.  Haemorrhage  may  be  controlled  by  plugging 
with  iodoform  gauze,  and  the  catheter  then  removed.  An  assist- 
ant should  watch  and  prevent  too  great  a  separation  of  the  bones. 
Some  now  leave  the  case  to  Nature,  waiting  from  one  to  twelve 
hours,  interfering  when  they  deem  it  advisable.  Others  proceed 
at  once  to  hasten  delivery,  dilating  the  os  if  necessary  and  apply- 
ing forceps  or  delivering  by  version.  An  assistant  should,  after 
delivery  of  the  child,  express  the  placenta  and  keep  the  uterus 
contracted.  The  catheter  may  now  be  reintroduced  to  prevent 
the  urethra  from  being  caught  between  the  bones.  The  abdom- 
inal wound  is  sutured,  the  lowest  suture  passing  through  the  upper 


EMBRYOTOMY  563 

cartilaginous  surface  of  tho  symphysis.  Tho  bones  should  not  be 
wired.  An  antiseptic  dressing  is  applied  and  retained  in  position 
by  adhesive  strapping;  the  vagina  is  loosely  packed  with  iodo- 
form gauze.  A  firm  abdominal  binder  is  then  applied  and  the 
limbs  bound  together,  first  placing  a  pad  between  the  knees.  The 
patient  should  be  kept  in  bed  for  from  three  to  five  weeks ;  and 
when  the  wound  is  completely  healed  an  immovable  apparatus 
should  be  put  on  to  fix  the  pelvis. 

The  Open,  French,  or  German  Method. — This  method  differs 
from  the  subcutaneous  in  that  an  open  incision  in  the  median  line 
3  or  4  inches  long  is  made,  beginning  ^  inch  or  1  inch  above  the 
upper  border  of  the  symphysis,  extending  to  the  root  of  the 
clitoris  or  a  little  to  one  side  of  it.  In  other  respects  the  two 
operations  are  the  same. 

The  operation  is  dang3rous  in  the  following  respects :  There 
may  be  considerable  haemorrhage  at  the  operation.  The  bladder, 
urethra,  or  vagina  may  be  injured.  Locomotion  may  be  impaired 
from  faulty  union  of  the  pelvic  bones  or  injured  sacro-iliac  syn- 
chrondrosis.     There  may  be  septicaemia. 

Operation  for  Ectopic  Pregnancy. — The  preparation  of  the 
patient  is  the  same  as  for  an  ordinary  laparotomy.  An  incision 
about  three  inches  long  is  made  in  the  abdominal  wall  in  the  median 
line,  extending  downward  from  just  below  the  umbilicus.  Two 
fingers  are  introduced  into  the  abdominal  cavity  and  the  uterus 
sought  for,  and  then  from  it  the  Fallopian  tubes  are  easily  found. 
The  enlarged  one  is  held  between  two  fingers  and  brought  out 
through  the  wound.  If  rupture  has  occurred  the  perforation  will 
generally  be  easily  visible.  The  broad  ligament  is  then  transfixed 
and  tied  with  interlocking  ligatures  and  the  tube  cut  away.  It 
is  generally  advisable  to  wash  out  the  abdominal  cavity.  The 
abdominal  wound  is  closed  in  the  usual  manner.  (The  symptoms 
of  ectopic  gestation,  before  and  after  rupture,  and  the  indications 
for  operation,  are  given  in  Chapter  XIV.) 

Embryotomy. — This  is  the  mutilation  of  the  foetal  body,  under- 
taken to  render  possible  extraction  of  the  child.  It  should  very 
rarely,  or  better  never,  be  performed  on  a  living  child.  Where 
the  patient  and  her  friends  absolutely  refuse  abdominal  section  it 
may  be  done  in  the  following  cases:  where  there  is  a  great  dis- 
proportion between  the  child's  head  and  the  mother's  pelvis; 
where  there  is  obstruction  in  the  genital  canal,  due  to  tumors. 


564  MAJOK  OBSTETRICAL    OPERATIONS 

cicatricial  contractions,  or  inflammatory  conditions  of  the  soft 
parts;  where  malpositions  and  malpresentations  have  caused 
impactions;  where  there  is  hydrocephalus  or  other  foetal  deform- 
ities ;  where  the  mother's  life  is  in  serious  danger  from  eclampsia, 
etc.  Some  divide  it  into  six  varieties :  (1)  craniotomy,  (2)  eviscer- 
ation, (3)  decapitation,  (4)  spondylotomy,  (5)  spondylolysis,  and 
(6)  amputation  of  extremities.     Others  divide  it  simply  into  two 


Fig.  215. — Simpson's  Perforator 


varieties :  craniotomy,  denoting  the  mutilation  of  the  foetal  head, 
and  embryotomy,  mutilation  of  the  foetal  trunk. 

Craniotomy. — This  is  perforation  and  extraction  of  the  foetal 
head.  The  following  instruments  are  required :  a  perforator 
(Simpson's  being  the  best),  a  cephalotribe  or  basiotribe  (head 
crusher),  a  craniotractor  or  cranioclast  (head  seizer),  a  pair  of 
volsella  forceps,  a  catheter,  and  antiseptic  solutions. 

Operation.  The  patient  should  be  placed  in  the  lithotomy 
position  and  the  bladder  and  rectum  emptied.     The  vulva  and 


Fig.  216. — Scissors  of  Smellie. 


vagina  should  be  made  as  nearly  aseptic  as  possible.  The  head 
is  fixed  by  an  assistant  exerting  pressure  on  it  from  above,  and 
the  scalp  seized  by  the  volsella  near  the  point  of  intended  perfo- 
ration. The  left  index  finger  is  used  as  a  guide  and  a  suture  or 
fontanelle  found,  through  which  the  head  is  perforated.  If  neither 
suture  nor  fontanelle  can  be  found,  perforation  may  be  made 
through  a  bony  plate,  such  as  the  parietal  bone.     Others  think  it 


CRANIOTOMY 


565 


better  to  perforate  thr()Uf;h  the  presenting  part,  whether  it  be 
bone,  suture,  or  foiitanelle.  In  cases  of  face  presentation  it  is  best 
to  perforate  throu.iih  the  more  accessil)l(;  orbit,  or,  faiUng  that, 


Fig.  217. — Method  of  Perforating  Head  (Williams). 

through  the  roof  of  the  mouth.  Care  should  be  taken  lest  the 
perforator  slip ;  it  is  least  apt  to  do  so  if  kept  near  the  symphysis. 
When  the  perforator  is  inserted  the  points  should  be  opened  by 
pressure  on  the  handles.  The  points  are  then  closed  again,  the 
instrument  turned  on  its  ax's  through  a  right  angle  and  the  pro- 
cess repeated.  The  brain  substance,  especially  the  medulla,  is  then 
destroyed,  and  may  be  washed  out  if  necessary  with  a  stream  of 


Fig.  218. — Br.\un's  Cranioclast. 


sterilized  water  through  a  Davidson's  syringe.  (In  some  cases 
after  failure  to  deliver  with  forceps,  it  is  well  to  perforate  without 
removing  them  and  then  reapply  traction.) 


566 


MAJOR  OBSTETKICAL    OPERATIONS 


Extraction.  The  child  may  in  some  cases  be  extracted  with 
forceps ;  in  others  a  cephalotribe  is  used.  The  narrow  blades  are 
applied  to  the  sides  of  the  skull  Uke  ordinary  forceps  and  are  made 
to  approach  and  to  crush  the  skull  by  means  of  a  screw  at  the  ends 
of  the  handles.  Others  use  a  cranioclast,  applying  one  blade 
within  the  skull  and  the  other  without,  but  underneath  the  scalp. 
It  may  be  necessary  in  some  cases  to  break  up  the  base  of  the 
skull  with  a  basylist  or  basiotribe  before  extraction.     Jellett  rec- 


FiG.  219. — Head  Crushed  by  Braun's  Cranioclast  (Simpson). 


ommends  for  compression  and  extraction  Winter's  modification 
of  Auvard's  combined  cranioclast  and  cephalotribe,  which  con- 
sists of  three  blades,  a  central  or  male  blade  resembling  the  male 
blade  of  an  ordinary  Barnes's  cranioclast,  and  two  outside  blades 
which  both  lock  into  the  central  blade.  One  of  these  outside 
blades  locks  with  the  central  blade  so  as  to  form  a  cranioclast,  the 
other  completing  the  cephalotribe.  The  Auvard  instrument,  how- 
ever, is  much  superior  to  this  modification. 


PORRO'S   OPERATION  567 

Evisceration. — This  is  the  operation  of  oix'iiiiig  the  thorax  or 
abdomen  of  the  child  and  removing  some  of  the  viscera.  It  is 
indicated  in  those  cases  where  the  size  of  the  child's  body  prevents 


Fig.  220. — Tarnier's  Cephalotribe. 

delivery.  A  perforator  or  a  pair  of  scissors  is  introduced  into 
whatever  portion  of  the  trunk  is  most  accessible.  Through  this 
opening  the  hand  is  passed  and  some  of  the  larger  viscera — liver, 
lungs,  or  heart — are  removed.  The  hand  is  then  passed  into  the 
uterus,  a  foot  seized  and  the  child  extracted. 

Decapitation. — This  is  the  operation  where  the  child's  head  is 
separated  from  the  trunk  at  the  neck.  It  is  indicated  in  cases  of 
neglected  shoulder  presentations  when  the  neck  can  be  reached. 
A  Braun's  blunt  hook  is  passed  over  the  neck  and  the  soft  parts 
and  spinal  column  torn  through.  (Ramsbotham's  hook  is  pre- 
ferred by  most  British  obstetricians.)     The  arms  are  then  drawn 


Fig.  221. — Simpson's  Basylist,  Disarticulated. 

down  and  the  trunk  extracted  first,  then  the  head.  When  it  is 
difficult  or  impossible  to  extract  the  head,  perforation  of  it  may 
be  necessary. 

Summary. — In  all  references  to  the  major  operations,  includ- 
ing the  brief  summaries  of  the  indications  for  the  same,  an  endeavor 
has  been  made  to  give  the  views  of  the  majority  of  obstetricians. 
But  it  should  be  remembered  and  fully  appreciated  that  we  are 


568 


MAJOR  OBSTETEICAL    OPERATIONS 


now  passing  through  an  evolution  stage,  and  our  views  are  chang- 
ing rapidly.  Conservative  Csesarean  section  is  becoming  very  pop- 
ular.    In  skilled  hands  its  mortality  has  been  diminished  to  such 


Fig.  222. — Simpson's  Basylist,  Aetictjlated. 

an  extent  that  it  is  now  placed  at  3  to  4  per  cent,  in  cases  where 
the  women  have  not  been  infected  before  the  operation. 

Porro's  supravaginal  amputation  of  the  cervix  after  removal 
of  the  child  was  popular  for  many  years  after  its  introduction  in 
1876.  Since,  however,  Sanger  introduced  his  method  of  perform- 
ing Csesarean  section  in  1882  the  Porro  operation  has  rapidly  lost 
ground.  One  of  the  supposed  advantages  of  the  Porro  with  the 
extraperitoneal  treatment  of  the  stump  was  that  it  could  be  more 
easily  performed  by  a  general  practitioner  who  was  not  an  expert 
abdominal  surgeon.  It  was  also  thought  it  was  a  safer  operation 
when  there  was  infection,  and  that  it  could  be  performed  more 
easily  than  the  Csesarean  section.  The  surgeon  of  to-day,  how- 
ever, does  not  attach  much  importance  to  these  considerations,  and 
generally  considers  it  a  very  unsatisfactory  if  not  crude  operation. 

Symphysiotomy  is  also  fast  losing  its  short-lived  popularity. 
In  a  late  report  Tissier,  of  Paris,  gave  notes  of  the  after-histories  of 


c± 


Fig.  223. — Braun's  Blunt  Hook. 


twenty  women  who  had  been  dehvered  by  symphysiotomy  during 
the  period  1898-1903.  The  patients  were  operated  on  at  seven 
different  hospitals.     Four  only  out  of  the  twenty  escaped  without 


POKRO'S   OPERATION 


569 


some  undesirable  sequelse,  the  remaining  sixteen  all  being  more 
or  loss  damaged  by  the  operation.  One  patient  has  })een  a  chronic 
invalid  for  five  years.  Eight  suffered  from  phlebitis.  Ten  had 
urinary  troubles  during  months  or  years,  incontinence  of  urine 
being  the  most  common  affection.  A  number  had  difficulty  in 
lifting  or  going  up-stairs.  A  few  years  ago  the  operation  was  in 
a  large  proportion  of  cases  con- 
sidered successful  when  it  did 
not  cause  the  death  of  the 
patient.  Many  of  the  operators 
were  not  frank,  or  at  least 
prompt,  in  reporting  the  remote 
disastrous  results  such  as  those 
mentioned  by  Tissier.  While  it 
has  many  disadvantages,  it  is 
doubtful  if  it  has  one  advantage 
over  Caesarean  section. 

From  the  present  trend  of 
obstetrical  surgery  it  seems  not 
unlikely  that  Porro's  operation 
and  symphysiotomy  will  soon 
be  obsolete.  It  is  to  be  hoped 
that  all  forms  of  embryotomy 
of  the  living  child  will  be  placed 
in  the  same  category. 

It  is  not  improbable  that  in 
the  near  future  the  following 
rules  will  prevail :  When  Nature 
fails  to  expel  the  child  and  we 
cannot  safely  complete  deliv- 
ery by  version  or  forceps,  we 
must  choose  a  major  operation. 
Caesarean    section   will    be   the 

operation  of  election  in  the  great  majority  of  cases ;  total  hyster- 
ectoniy  will  be  the  operation  of  election  in  a  few  exceptional 
cases  when  infection  is  recognized  or  suspected ;  embryotomy  will 
be  the  operation  of  election  when  the  child  is  dead  and  there  is 
only  slight  pelvic  deformity. 


Fig.  224.  —  Decapitation  with 
Braun's  Blunt  Hook  (Americaii 
Text-Book). 


INDEX 


Abdomen,  discoloration  of,  in  preg- 
nancy, 37. 

enlargement  of,  during  pregnancy, 
30. 

palpation  of,  72,  87. 

pendulous,  36,  212. 

stritc  of,  in  pregnancy,  37. 
Abdominal  binder,  133. 

pregnane}^  61. 
Abortion,  359. 

causes  of,  360. 

cervical,  372. 

clinical  history  of,  363,  368. 

complete,  372. 

criminal,  359. 

curettage  in,  368. 

incomplete,  372. 

induction  of,  519. 

inevitable,  362. 

missed,  370. 

mole,  formation  of,  in,  362. 

neglected,  372. 

prophylaxis  of,  361. 

repeated  (aborting  habit),  361. 

threatened,  362. 

treatment  of,  362,  368. 

tubal,  315,  319. 

vaginal  tamponade  in,  366. 
Abscess  in  puerperal  fever,  466. 

of  breast,  423. 

pelvic,  453. 
Acardiacus,  186. 
Accidental  htemorrhage,  333. 
Accouchement  force,  522. 
Acute    infectious    diseases    in    preg- 
nancy, 232. 
Adhesions,  amniotic,  231. 


Adipocere,  330. 
After-coming  head,  181. 
After-pains,  149. 
Agalactia,  398. 

Age  of  foetus,  calculation  of,  23. 
Albuminuria,  273,  285,  289. 
Albuminuric  retinitis,  274. 
Alimentation,  rectal,  in  hyperemesis, 

195. 
Allantois,  19. 

Amaurosis  during  pregnancy,  274. 
Amenorrhoea,  conception  during,  40. 
Amnion,  19. 

diseases  of,  228. 
Amniotic  fluid,  228. 
Amputation,  intra-uterine,  231. 
Anaemia  in  pregnancy,  200. 
Anaesthesia,  142. 

cocaine,  145. 

in  heart  disease,  262. 
Anencephalus,  407. 
Anteflexion  of  pregnant  uterus,  211. 

of  puerperal  uterus,  148. 
Anteversion  of  pregnant  uterus,  211. 
Antisepsis,  97. 

Antistreptococcic  serum,  462. 
Anus,  laceration  of  sphincter  of,  516. 

imperforate,  491. 
Apoplexy  in  eclampsia,  298. 
Appendicitis  during  pregnancy,  242. 
Arbor  vitae  uterina,  9. 
Areola,  glands  of  Montgomery,  40. 

of  pregnancy, 40. 
Artificial  feeding,  163. 

respiration,  136. 
Ascites,  of  foetus,  400,  406. 

of  mother  simulating  pregnancy,  50. 
571 


572 


INDEX 


Asepsis,  97. 

Asphyxia,  neonatorum,  136. 

resuscitation  from,  136-138. 
Atelectasis,  136. 
Atony  of  uterus,  375. 
Atresia  of  genital  canal,  49. 
Attitude  of  foetus,  30.  * 

Auscultation,  obstetrical,  77,  89. 
Auto-infection,  442. 
Auto-intoxication  of  pregnancy,  284. 
Axis  of  pelvis,  4. 
Axis  traction  forceps,  543,  546. 

Babe,  management  of  the,  135. 

dressing  the,  139. 

Gertrude  suit,  139. 

washing  the,  139. 
Bacillus  diphtherise  in  puerperal  in- 
fection, 439. 
Bacteriology  of  lochia,  456. 

of  puerperal  infection,  438. 

of  vaginal  secretions,  366. 
Bag  of  waters,  membranes,  71. 
Bags,  Voorhees's  dilating,  527. 
Balloon,  Champetier  de  Ribes's,  525, 

526. 
Ballottement,  44. 
Bandl's  ring,  31,  67. 
Barker,  Fordyce,  434. 
Barnes's  fiddle-bags,  524. 
Bartholin's      glands      (vulvo-vaginal 

glands),  7,  270. 
Basilyst,  Simpson's,  567,  568. 
Basiotribe,  Simpson's,  567. 
Bath,  during  labor,  90. 

of  new-born  child,  139. 

sweat  in  eclampsia,  293. 
Battledore  placenta,  403,  408. 
Bichloride  poisoning  from  intra-uter- 

ine  douche,  504. 
Bicornuate  uterus,  11. 
Binder,  use  of,  during  puerperium, 

133. 
Binovular  twins,  188. 
Bipolar  version,  345. 
Birthmarks,  135. 

Bladder,    changes    in,    during    preg- 
nancy, 280. 


Bladder,  distended  before  labor,  108. 

distended  after  labor,  151. 

distended  during  labor,  395. 

empty  after  labor,  150. 

empty  before  labor,  108. 
Bleeding  in  eclampsia,  300. 
Blood,  changes  in,  during  pregnancy, 
34. 

during  puerperium,  471. 
Blunt  hook,  568. 
Bossi's  dilator,  528. 
Bougie,   for  induction  of  premature 

labor,  520. 
Bowels  in  pregnancy,  61. 
Braun's  blunt  hook,  568. 

cranioclast,  565. 
Braxton  Hicks's  method  of  version, 

345,  531. 
Breasts,  14. 

anatomy  of,  14. 

areola  of,  14,  40. 

binder,  156,  245. 

care  of,  during  nursing,  155. 

inflammation  of,  420. 

in  pregnancy,  40. 

massage,  156,  425. 

supernumerary  (polymastia),  37. 
Breech  presentations,  175,  179. 
Bright's  disease,  273,  275. 
Brim  of  pelvis,  2. 
Broad  ligament  pregnancy,  321. 
Broad  ligaments  in  normal  pregnancy, 

33. 
Bronchocele  in  pregnancy,  240. 
Brow  presentations,  175. 
Byrd's  method  of  resuscitation,  137. 

Cesarean  section,  559. 

conservative,  568. 

technique  of,  559. 

vaginal,  560. 
Calcification  of  foetus,  330. 

of  placenta,  408. 
Callus  formation,  effect  upon  pelvis, 

482. 
Canal,  cervical,  32. 
Cancer,  346,  347. 
Caput  succedaneum,  489. 


INDEX 


573 


Carcinoma  of  cervix  with  pregnancy, 
346,  347. 

of  rectum,  case  of  dystocia,  395. 
Cardiac  lesions  in  pregnancy,  257. 
Cams,  circle  of,  4. 
Catheterization,  501. 
Caul,  117. 

Causation  of  labor,  65. 
Cellulitis  in  puerperal  infection,  452. 
Central  placenta  pra^via,  343. 
Cephalha^matoma,  489. 
Cephalic  version,  401. 
Cephalopagus,  406. 
Cephalotribe,  Tarnier's,  567. 
Cervix,  9. 

anatomy  of,  10. 

apparent   shortening   of,    in   preg- 
nancy, 32. 

arbor  vitff,  9. 

atresia,  392. 

carcinoma  of,  346. 

changes  in,  after  labor,  152. 

changes  in,  during  labor,  32,  42. 

dilatation  of,  during  labor,  101. 
manual,  524. 
with  forceps,  534. 

during  pregnancy,  32. 

glands  of,  10. 

hypertrophy  of,  during  pregnancy, 
392. 

incision  of,  528. 

rigidity  of,  392. 

softening  of,  in  pregnancy,  42. 

taking-up  process  in  labor,  71. 

tears  of,  508. 
Champetier  de  Ribes's  balloon,  524. 
Child  (see  New-born  Child),  160. 
Chill,   during  puerperium,   149,   445, 
450. 

following  normal  labor,  140. 

in  puerperal  infection,  445. 
Chloral  in  labor,  145. 
Chloroform  in  labor,  142. 
Cholera  complicating  pregnancy,  237. 
Chorea  during  pregnancy,  204. 
Chorio-epithelioma,  372. 
Chorion,  19. 

cystic  degeneration,  226. 


Chorion,  Langhans's  layer  of,  372. 

pathology  of,  226. 

syncytium  of,  372. 

villi  of,  19. 
Circulation  of  fcEtus,  28. 

in  new-born  child,  28. 
Clitoris,  7. 
Cloasma,  207. 

Clothing  during  pregnancy,  61. 
Club  foot,  492. 

Cocaine  ana?sthesia  in  labor,   145. 
Coccyx,  1. 
Coelome,  23. 
Cohen's   method   of   inducing   labor, 

522. 
Coiling  of  cord,   409. 
Coitus  during  pregnancy,  61,  361. 
Colic,  495. 

Collapse  from  haemorrhage,  354. 
Colles's  law,  266. 
Colon  bacillus,  439. 
Colostrum,  152. 
Complete  abortion,  372. 
Compound  presentation,  401. 
Concealed      hsemorrhage,    334,    340, 

350. 
Conception,  16. 
Condensed  milk,  166. 
Conduct  of  normal  labor,  85. 
Confinement,  estimation  of  date  of, 

52. 
Conglutinatio  orificii  externi,  392. 
Conjugata  diagonalis,  55. 

externa,  55. 

vera,  84,  484. 
Conservative  Caesarean  section,  559, 

568. 
Constipation  during  pregnancy,  197. 

dietetic  treatment  of,  197. 

hygienic  treatment  of,  198. 

medicinal  treatment  of,  198. 
Contracted  pelves,  482. 

craniotomy  in,  482. 

due  to  tumors,  etc.,  482. 

mechanism  of  labor  in,  483. 

pelvimetry  in,  54. 

treatment  of  labor  complicated  by, 
484. 


574 


INDEX 


Contraction,  68,,  69. 

hour-glass  of  uterus,  348,  418. 

painless,  47. 

uterine,  68. 

ring,  31,  67. 
Convulsions  (see  Eclampsia),  294. 
Copeman's  dilatation  of  the  cervix, 

196. 
Cord   (see  Umbilical  Cord),  23,  117, 

408. 
Coronal  suture,  27. 
Corpulence  simulating  pregnancy,  50. 
Corpus  luteum,  15. 

false,  15. 

true,  15. 
Correction    of    displacement    of    the 

uterus,  197. 
Corrosive  sublimate,  504. 
Cramps,  muscular,  during  pregnancy, 

207. 
Cranioclast,  565. 
Craniotomy,  564. 
Cranium  (see  Head,  Foetal),  27. 
Cream  mixtures,  163. 
Crede's   method    of   expressing    pla- 
centa, 121. 
Criminal  abortion.  359. 
Cul-de-sac  of  Douglas,  8. 
Curettage,  368,  504. 
Cyanosis,  infantile,  493. 
Cystic  degeneration  of  chorion,  226. 
Cystitis  during  pregnancy,  281. 
Cystocele  complicating  labor,  395. 

Death   of  foetus   during   pregnancy, 

136,  409. 
Decapitation,  567. 
Decidua,  18,  34. 

changes  in,  in  abortion,  34. 

compact  layer  of,  34. 

deep  layer  of,  34. 

development  of,  outside  of  uterus, 
313. 

diseases  of,  225. 

in  extra-uterine  pregnancy,  313. 

reflexa,  19. 

serotina,  19. 

spongy  layer  of,  34. 


Decidua  vera,  19. 

Decidual  cast  in  extra-uterine  preg- 
nancy, 324. 
Deciduoma  malignum,   372. 
Deformed  pelves  (see  Contracted  Pel- 
ves), 482. 
Delivery,  normal,  85. 
Dental  caries  during  pregnancy,  193. 
Diabetes  during  pregnancy,  283. 
Diagnosis,  differential,  of  pregnancy, 
48. 

of  life  or  death  of  foetus,  409. 

of  pregnancy,  38. 

of  previous  pregnancy,  53. 

of  sex  during  pregnancy,  46. 
Diameters  of  head,  27. 

of  pelvis,  55,  84. 
Diarrhoea  during  pregnancy,  199. 
Dicephalous  monsters,  406. 
Diet  during  pregnancy,  61. 

during  puerperium,  159. 
Differential  diagnosis  of  pregnancy, 
48. 

of  foot  and  hand,  177- 

of  knee  and  elbow,  177. 
Dilatation  of  cervix,  196,  519. 

in  labor,  523. 
Dilator,  Bossi's,  528. 
Diseases     complicating     pregnancy, 

192. 
Displacements  (see  Uterus),  212. 
Dolichocephalic  head,  cause  of  face 

presentation,  169. 
Double  Naegele  pelvis,  481. 

uterus,  11. 

vagina,  11. 
Douche,  uterine,  503. 

prophylactic,  154. 

vaginal,  502. 

vulvar,  502. 
Douglas's  cul-de-sac,  33. 
Dropsy  of  amnion,  228. 
Dry  labor,  377,  382. 
Duchenne's  paralysis,  491. 
Duct  of  Gartner,  12. 
Ducts,  lactiferous,  14. 
Ductus,  arteriosus,  28. 

venosus,  28. 


INDEX 


575 


Duration  of  prepjiancy,  51. 
Dwarf  pelvis,  481. 
Dyspna?a  during  pregnancy,  202. 
Dystocia  due  to  abnormalities  of  the 
cervix,  392. 
to  abnormalities  of  the  expulsive 

forces,  386. 
to  abnormalities     of     vagina    and 

vulva,  392,  396. 
to  contracted  pelves,  482. 
to  tumors  of  birth  canal,  394. 
Dystocia  following  vagino-fixation  or 

ventro-fixation,  393. 
Dysuria  from  incarcerated  pregnant 
uterus,  213. 

Eclampsia,  294. 

blindness  accompanying,  274. 

frequency  of,  294. 

induction  of  abortion  for,  306. 

pathology  of,  297. 

prognosis  of,  297. 

treatment  of,  298. 

venesection  in,  300. 
Ectopic  pregnancy  (see  Extra-uterine 

Pregnancy),  310. 
Elderly  primipara^,  377. 
Embolism,  air,  503. 

pulmonary,  475. 
Embryo,  18. 
Embryotomy,  563. 
Emesis  in  pregnancy,  194. 
Emotional  disturbances,  203,  427. 
Endometritis,     catarrhal,     decidual, 
226. 

puerperal,  443. 

septic,  443. 
Enema,  during  labor,  98. 

high,  500. 
Enteroptosis  during  pregnancy,  199. 
Epiblast,  18. 

Epilepsy  during  pregnancy,  296. 
Episiotomy,  508. 
Ergot,  use  of,  in  labor,  131,  384. 
Er^'sipelas  in  pregnancy,  235. 
Erythema  intertrigo,  494. 
Esmarch  mask,  143. 
Estimation  of  date  of  confinement,  51. 
38 


Ether,  144,  145. 
Eustachian  valve,  28. 
Evisceration,  567. 
Evolution,  spontaneous,  400. 
Examination,  87. 

preliminary,  during  pregnancy,  62. 

vaginal,  during  labor,  89. 
during  pregnancy,  77. 
Exostosis,  producing  pelvic  deform- 
ities, 482. 
Expelling  powers  in  labor,  65. 
Expression  of  placenta,  124. 
External  conjugate  measurement,  58. 
External  version,  531. 
Extra-uterine  pregnancy,  310. 

abdominal,  321,  329. 

abortion  in,  315,  319. 

associated  with  intra-uterine,  327. 

Tittachment  of  ovum  in,  313. 

broad  ligament,  321,  326. 

classification  of,  311,  312,  322. 

corpus  luteum  in,  314. 

decidua  expelled  entire  in,  324. 

diagnosis  of,  322,  323. 

etiology  of,  312. 

fate  of  foetus  in,  330. 

formation  of  decidua  in,  313. 

formation  of  placenta  in,  313. 

hematocele  in,  318,  320. 

interstitial,  317,  324. 

lithopa?dion  in,  330,  331. 

mole,  315. 

mummification  in,  330. 

ovarian,  312. 

primary,  313. 

rupture  of,  314,  316,  325. 

secondary,  321. 

suppuration  in  sac,  330. 

symptoms  of,  318. 

terminations  of,  330. 

treatment  of,  330. 

tubal,  312. 

tubo-abdominal,  321. 

tubo-ligamentous,  321. 

uterine  decidua  in,  313. 

Face  presentations,  168. 

conversion  of,  into  vertex,  173. 


576 


INDEX 


Face  presentations,  diagnosis  of,  169. 

management  of,  172. 

mechanism  of,  170. 

treatment  of,  174. 

version  in,  172. 
Facial   paralysis    during   pregnancy, 

206. 
Factory    employment    during    preg- 
nancy, 241. 
Fseces  of  infant,  160. 
Fallopian  tubes,  9,  11. 
False  pregnancy,  50. 
Farre,  white  line  of,  13. 
Fascia,  pelvic,  5. 
Fat   in   abdominal   walls   simulating 

pregnancy,  50. 
Fatty  degeneration  of  placenta,  408. 
Fecundation,  16. 
Fertilization  of  ovum,  16. 
Fibro-m.yomatum  of  uterus,  compli- 
cating labor,  225. 
Fillet,  180. 
Fissure  of  nipple,  423. 
Flat  pelvis,  481. 

Flexion  in  vertex  presentations,  79. 
Foetal  circulation,  28. 

diseases,  409. 

dropsy,  406. 
Foetal  heart  sounds,  45,  77,  89. 
Fojtal  head,  27. 

nervous  system,  29. 
Foetus,  18. 

ascites  of,  400,  409. 

at  full  term,  26. 

attitude  of,  30. 

calcification  of,  330. 

circulation  of,  28. 

congenital  hydrocephalus,  409. 

cranium  of,  27. 

death  of,  136,  409. 

deformities  of,  405. 

diameters  of  head  of,  27. 

diseases  of,  409. 

head  of,  27. 

heart  sounds  of,  in  pregnancy,  45, 
46. 

hydrocephalus  of,  406. 

lanugo  of,  25. 


Foetus,  large,  407. 

lie  of,  30. 

length  of,  26. 

maceration  of,  409. 

malformations  of,  405. 

meconium  of,  160. 

movements  of,  in  pregnancy,  45. 

nutrition  of,  22. 

over-development  of,  407. 

papyraceus,  187. 

peritonitis  of,  409. 

physiology  of,  IS. 

position  of,  30. 

presentation  of,  30. 

pressure  marks  on  head  of,  490. 

syphilis  of,  409. 

urine  of,  160. 
Footling  presentation,  176. 
Foramen  ovale,  28. 
Forceps,  534. 

application  of,  549,  550. 

as  dilator  of  cervix,  534. 

axis  traction,  543,  546. 

choice  of,  541. 

conditions  necessary  for  application 
of,  535. 

description  of,  543,  546. 

in  after-coming  head,  185. 

in  contracted  pelves,  485. 

indications  for,  535. 

locks,  540,  542,  543. 

long,   541. 

Milne  Murray's,  543. 

Pajot's  manoeuvre,  544. 

Porter  Mathew's,  546. 

Simpson's,  542. 

Tarnier's,  542. 
Forces  concerned  in  labor,  65, 
Fossa  navicularis,  7. 
Fourchette,  7. 
Fourth  grip,  76.  . 
Frontal  suture,  27. 
Fundal  grip,  74. 
Fundal  incision  in  Csesarean  section, 

560. 
Funic  souffle,  48. 

Funis  (see  Umbilical  Cord),  23,  117. 
Funnel-shaped  pelvis,  481. 


INDEX 


577 


Galactocele,  398. 

Galactorrhoea,  398. 

Gastroptosis,  during  pregnancy,  199. 

Gavage,  168. 

Generally  contracted  pelvis,  481. 

Generation,  16. 

Germinal  epithelium,  13. 

spot,  13. 
Gertrude  baby  suit,  139. 
Glands,     Bartholin's     (vulvo-vaginal 
glands),  7,  270. 

cervical,  10. 

mammary,  14. 

uterine,  9. 
Glycerine,  use  of,  in  inducing  labor, 

522. 
Glycosuria  during  pregnancy,  283. 
Goitre  in  pregnancy,  240. 
Gonococcus,  477. 

Gonorrhoea  in  pregnancy,  269,  476. 
Graafian  follicle,  13. 
Greater  fontanelle,  27. 
Grips  in  abdominal  palpation,  75. 
Guard,  vulvar,  63. 

Hsematocele,  diffuse,  318. 

pelvic,  319. 
Hematoma,  318,  320. 

of  broad  ligament,  318,  320. 

of    sterno-cleido-mastoid     muscle, 
490. 

of  vagina,  396. 

of  vulva,  396. 

subperitoneal,  320. 
Hsematometra,  49. 
Hsemoptysis  during  pregnancy,  250. 
Haemorrhage,  accidental,  333. 

ante-partum,  333. 

concealed  accidental,  333,  334. 

curettage  in,  363,  368. 

ergot  in,  131. 

post-partum,  349. 

unavoidable,  341. 
Harris's  method  of  dilating  the  cer- 
vix, 524. 
Head,  foetal,  27. 

diameters  of,  27. 

fontanelles  of,  27. 


Head,  of  new-born  child,  27. 

presentation,  77. 

sutures  of,  27. 
Headache  in  eclampsia,  295. 

in  pregnancy,  285. 
Heart,  disease  of,  in  pregnancy,  257. 

foetal,  45,  77. 

hypertrophy  of,  in  pregnancy,  258. 

means  of  diagnosing  sex,  46. 
Hegar's  sign  of  pregnancy,  42. 
Hemiplegia  in  pregnancy,  206. 
Herman's  method  in   face  presenta- 
tions, 173. 
Hernia  of  pregnant  uterus,  218. 
Herpes  gestationis,  208. 
Hook,  blunt,  568. 
Hour-glass  contraction  of  uterus,  349, 

418. 
Hydatidiform  mole,  226. 
Hydrsemia  of  pregnancy,  34. 
Hydramnios,  228. 
Hydrocephalus,  408. 
Hydrometra,  48. 
Hydrorrhoea  gravidarum,  226. 
Hygiene  of  pregnancy,  61. 
Hymen,  7. 

Hyperemesis  gravidarum,  194. 
Hypertrophic    elongation    of    cervix 

during  pregnancy,  392. 
Hypoblast,  18. 
Hypodermic  injection,  499. 
Hysterectomy,  561. 

Icterus  of  child,  492. 

Ilio-pectineal  line,  2. 

Ilium,  1. 

Imaginary  pregnancy,  50. 

Imperforate  anus,  135,  491. 

Impetigo  herpetiformis,  208. 

Impregnation,  16. 

Incarceration  of  retroflexed  pregnant 

uterus,  213. 
Incisions  of  cervix,  528. 
Incomplete  abortion,  372. 
Incubator,  167. 

Indigestion  during  pregnancy,  194. 
Induction  of  abortion,  519. 
of  premature  labor,  520. 


578 


INDEX 


Inertia  uteri,  375. 

Inevitable  abortion,  362. 

Infant,  135,  160. 

Infarcts  of  placenta,  408. 

Infection,  puerperal,  435. 

Infectious  diseases  complicating  preg- 
nancy, 232. 

Influenza  during  pregnancy,  238. 

Injuries  to  birth  canal,  133. 

Innominate  bone,  1. 

Insanity,  puerperal,  430. 

Insertio  velamentosa,  408. 

Insomnia  during  pregnancy,  203. 

Insufflation  of  lungs  in  asphyxia  neo- 
natorum, 138. 

Intercristal  measurement,  57. 

Intermittent     contractions     of     the 
uterus,  47. 

Internal  rotation,  79. 

Internal  version,  533. 

Interspinous  measurement,  56. 

Interstitial  pregnancy,  312,  317,  324. 

Intra-uterine  douche,  457,  503. 
dangers  of,  457. 

Intravenous  injection,  500. 

Inversion  of  uterus,  416. 

Involution  of  uterus,  147. 

Ischiopagus,  406. 

Ischium,  1. 

Jaundice  of  child,  492. 
Joints,     mobility     of,    during    preg- 
nancy, 3. 
relaxation  of,  during  pregnancy,  3. 

Kidney,    changes    in,    during    preg- 
nancy, 272. 
acute  nephritis,  273. 
chronic  nephritis,  273. 
toxemic,  272. 
Knee  presentation,  176. 
Krause's  method  of  inducing  labor, 

520. 
Kyphosis,  482. 

Labium  majus,  6. 

oedema  of,  397. 

Labium  minus,  7. 


Labor,  abdominal  contractions  dur- 
ing, 66. 
action  of  expellent  forces  in,  65. 
anaesthesia  during,  142. 
antisepsis  in,  97. 
asepsis  in,  97. 
bandage,  abdominal,  133. 
bed,  preparation  of,  for,  96. 
cause  of,  65. 
cervix  during,  71. 
chair,  Soudan,  119. 
chill  after,  149,  445,  450. 
collapse  after,  354. 
conduct  of,  85. 

first  stage  of,  71,  99. 

second  stage  of,  71,  105. 

third  stage  of,  71,  121. 
contraction  of  muscle  fiber  during, 

69. 
cord,  tying  of,  117. 
course  of,  in  contracted  pelves,  483. 
delivery  of  head,  109. 
delivery  of  shoulders,  116. 
diet  during,  100. 
dilatation  of  cervix,  524. 
dress  of  accoucheur,  95. 
dry,  377. 
duration  of,  71. 
enemata  during,  98. 
episiotomy,  508. 
ergot  during,  131. 
examination  in,  87. 
expelling  powers  in,  65. 
false,  330. 
first  stage  of,  98. 
forces  concerned  in,  65. 
in  elderly  primiparae,  377. 
introduction  of  hand  into  uterus 

during,  99. 
laceration  of  perinseum  during,  107, 

133,  510. 
lubricants  in,  97. 
management  of  normal,  85. 
mechanism  of,  in  breech  presenta- 
tions, 177. 

in  brow  presentations,  175. 

in  face  presentations,  170. 

in  vertex  presentations,  77. 


IXDEX 


579 


Labor,  missed,  330. 

molding;  of  head  in,  S3. 

nervous  influences  during,  67. 

normal,  S5. 

obstructed,  392. 

onset  of,  92. 

pains  of,  65,  66. 

palpation,  abdominal,  73,  87. 

perineal  tears  in,  108,  133. 

perineum,  management  of,  107. 

phenomena,  clinical  of,  8.5. 

physical    changes    during    uterine 
contractions,  67. 

physiology  of,  65,  378. 

position  in  first  stage  of,  101. 

position  in  second  stage  of,  109. 

precipitate,  374. 

prediction  of  date  of,  52. 

premature,  360. 

preparations  for,  90,  91. 

progress  of,  101. 

prolonged,  374. 

retraction  of  muscle  during,  70. 

room  prepared  for,  92. 

rules  for  doctor  during,  94. 

rules  for  nurse  during,  94. 

rupture  of  membranes  in,  105. 

second  stage,  105. 

shock  during,  340. 

stages  of,  71. 

taking   up   process   of   the   cer\-ix 
during,  71. 

temperature  in,  150. 

third  stage  of,  121. 

tying  of  cord  in,  117. 

vaginal  examination  during,  89. 

value  of  intermittent  character  of 
the  pains  in,  66. 
Laborde's    method    of   resuscitation, 

137. 
Laceration    during   labor,    107,   133, 
510. 

of  cervix,  508. 

of  cord,  398. 

of  pelvic  floor,  510. 

of  perin^eum,  510,  513. 

of  vagina,  509. 
Lactation,  152. 


Lactosuria  during  pregnancy,  283. 

Langham's  layer  of  chorion,  373. 

Lanugo,  25. 

Laparotomy    in    extra-uterine    preg- 
nancy, 330. 

Laxatives  in  puerperium,  61,  197. 

Lead    poisoning    during    pregnancy, 
240. 

Leg-holder,  95,  .543. 

Lesser  fontanelle,  27. 

Leucocytosis,  35,  471. 

Leucopenia,  469. 

Leucorrhoea  of  pregnancy,  218. 

Levator  ani  muscle,  6,  112. 

Lie  of  foetus,  30. 

Life,  perception  of,  45. 

Ligaments,  3,  11,  33. 

Lithopa^dion,  3.30,  331. 

Liver,  changes  in  eclampsia,  297. 

Lochia,  151. 

bacteriological  examination  of,  456. 

Locked  twins,  399,  403. 

Loops  in  umbilical  cord,  408. 

Lord  Lister,  152. 

Lower  uterine  segment,  31,  67. 

Lubricants  in  labor,  97. 

Lungs,  changes  in,  during  pregnancy, 
36. 

Lying-in  chamber,  96. 

Maceration  of  foetus,  409. 
Malaria  during  pregnancy,  239. 
Malpresentations,  399. 
Mammae  (see  Breasts),  14,  420. 
Mammarj'   glands,    management    of, 

14,  40,  1.55. 
Management  of  pregnancy,   61. 
Mania,  430. 

Manual  removal  of  placenta,  419. 
Manufactured  artificial  foods,  166. 
Marginal  insertion  of  cord,  407. 
Marginate  placenta,  407. 
Masculine  pelvis,  2. 
Massage  of  breasts,  156,  425. 
Mastitis,  420. 
Mathew's  forceps,  546. 
Maturity  of  foetus,  signs  of,  26. 
Measles  during  pregnancy,  236. 


580 


INDEX 


Mechanism  of  labor,  complicated  by 
foetal  monstrosities,  405. 

in  breech  presentations,  177. 

in  brow  presentations,   175. 

in  contracted  pelves,  483. 

in  face  presentations,  170. 

in  occipito-posterior  presentations, 
385. 

in  transverse  presentations,  400. 

in  vertex  presentations,  77. 
Meconium,  160. 
Membranes,  foetal,  129. 

extraction  of,  125. 
Membranous  placenta,  408. 
Menopause,  16. 
Menses,  cessation  of,  in  pregnancy,  40. 

persistence  of,  in  pregnancy,  40. 
Menstruation,  16. 

causation  of,  16. 

cessation  of,  in  pregnancy,  40. 

relation  of,  to  ovulation,  16. 
Mental  and  emotional  changes  during 

pregnancy,  203,  427. 
Mercurial    poisoning     in    pregnancy, 

240. 
Mesoblast,  18. 
Metritis,  puerperal,  444. 
Micturition  during  the  puerperium, 

159. 
Milk,  condensed,  166. 

corpuscles,  152. 

cow's,  163. 

fever,  152. 

human,  152,  163. 

leg  (see  Phlegmasia  Alba  Dolens), 
445. 

modified,  164. 

pasteurization  of,  163. 

sterilization  of,  163. 
Milne  Murray's  forceps,  543. 
Miscarriage  (see  Abortion),  250,  359. 
Missed  abortion,  317. 

labor,  330. 
Mixed  infection,  441. 
Mole,  362. 

hydatidiform,  226. 

tubal,  315. 
Monsters,  405. 


Mons  veneris,  6. 
Montgomery's  glands,  14. 
Morning  sickness,  40. 
Movements  of  foetus  during  pregnan- 
cy, 45. 
Miiller's    method    of    impression    of 

head,  485. 
Multiple  pregnancy,  185. 

acardia  in,  186. 

course  of  labor  in,  191. 

diagnosis  of,  191. 

foetus  papyraceus  in,  187. 

pathological  conditions  in,   190. 

presentation  in,  190. 

relation    of    placenta    and    mem- 
branes in,  191. 

treatment  of,  191. 
Muscle  fibers  of  pregnant  uterus,  68. 
Musculature  of  pregnant  uterus,  68. 
Myoma  of  uterus,  222. 

complicating  labor,  223. 

pregnancy,  222. 

Nabothian  follicles,  10. 

Naegele's  obliquity,  483. 

Naegele  pelvis,  481. 

Nausea  and  vomiting  in  pregnancy, 

194. 
Nephritis,  chronic,  during  pregnancy, 
272. 

morbid  anatomy  of,  277. 
Nervous  system  in  pregnancy,  202. 
Neuralgia  during  pregnancy,  202. 
New-born  child,  artificial  feeding  of, 
163. 

adherent  prepuce  of,  495. 

asphyxia  of,  136. 

bladder  of,  191. 

breasts,  engorgement  of,  491. 

cephalhsematoma  of,  489. 

circulatory  changes  in,  28. 

club  feet  of.  492. 

colic  of,  495. 

cyanosis  of,  493. 

ductus  arteriosus  of,  28. 

erythema  intertrigo  of,  494. 

eyes  of,  injuries  of,  490. 

feeding  of,  161. 


INDEX 


581 


New-bom  child,  foramen  ovale  of,  28. 

head  of,  27. 

icterus  of,  492. 

jaundice  of,  492. 

loss  of  weight  of,  161.  • 

nursing  of,  162. 

ophthalmia  of,  492. 

phimosis  of,  495. 

spina  bifida  of,  492. 

stomach  of,  161. 

syphilis  of,  493. 

tetanus  of,  493. 

tongue-tie  in,  494. 

umbilical  cord  of,  161. 

umbilical  haemorrhage  of,  491. 

umbilical  hernia  of,  491. 

umbilical  vegetations,  491. 

urine  of,  160. 

weight  of,  161. 

wet  nurse,  162. 
Nipple  shield,  424. 
Nipples,  61. 

care  of,  during  pregnancy,  61. 

during  puerperium,  1.58. 

excoriation  of,  423. 

fissures  of,  423. 

retracted,  61,  158. 
Nourishment,  administration  of,  168. 
Nuchal  presentation,  402. 
Nuclein,  use  of,   in  puerperal  infec- 
tion, 464. 
Nymphse,  3. 

Obliquely  contracted  pelvis,  481. 
Obliquity  of  the  uterus,  169. 
Obstetrical  outfit,  94. 
Obstructed  labor  (see  Dystocia),  392. 
Occipito-anterior    presentations,    78, 

83. 
Occipito-posterior  presentations,  385. 
CEdema  in  pregnancy,  287. 
ffidema  of  the  vulva,  397. 
Oligo-hydramnios,  231. 
Oophoritis,  puerperal,  444. 
Operations,  obstetrical,  496. 

accouchement  force,  522. 

Caesarean  section,  559. 

craniotomy,  564. 


Operations,  curettage,  368,  504. 

decapitation.  .567. 

douche,  154,  503,  504. 

embryotomy,  563. 

evisceration    in    breech    presenta- 
tions, 180. 

forceps,  534. 

induction  of  abortion,  519. 

induction  of  premature  labor,  520. 

intra-uterine  pack,  .353,  .507. 

manual  removal  of  placenta,  419. 

preparations  for,  498. 

repairing  of  lacerations,  513. 

symphyseotomy,  561. 

tampon,  353,  366,  .507. 
Ophthalmia  neonatorum,  492. 
Organ  of  Ro-senmiiller,  12. 
Os  externum,  9. 

enlargement  of,  in  pregnancy,  42. 

innominatum,  1. 

internum,  9,  32. 
Osteomalacia,  480. 
Osteomalacic  pelvis,  482. 
Ovarian  tumors,  49,  394. 

pregnancy,  312. 
Ovaries,  12. 

Graafian  follicles,  15. 
Ovariotomy  during  pregnancy,  394. 
Ovula  Nabothi,  10. 
Ovulation,  15. 

relation  of,  to  menstruation,  15. 
Ovule,  13. 
Ovum,  13. 

development  of,  18. 

diseases  of,  during  pregnancy,  225. 

impregnation  of,  16. 
Oxytocics,  indications  for  use  of,  131, 
384,  385. 

Painful     mammary     glands     during 

pregnancy,  221. 
Palpation,  72,  87. 
different  grips  in,  73. 
in  anterior-occipito-iliac  presenta- 
tions, 386. 
in  face  presentations,  169. 
of  cephalic  prominence,  176. 
of  foetal  heart-beat,  410 


582 


INDEX 


Palpation  of  lower  uterine  segment, 

45. 
Paraglobulin  in  urine  of  pregnancy, 

286. 
Paralysis,  Duchenne's,  491. 
during  pregnancy,  206. 
during  puerperium,  206. 
facial,  following  forceps,  491. 
of  nerves  of  special  sense  during 
pregnancy,  206. 
Parametritis,  444,  4.52. 
Paraplegia   complicating  labor,   206. 

during  pregnancy,  206. 
Parovarium,  12. 
Partial  placenta  prsevia,  341. 
Parturition  (see  Labor),  65,  77,  85. 
Pathology   of  labor,   333,   374,  399, 
410. 
of  pregnancy,   192,  210,  232,  272, 

310. 
of  puerperium,  272. 
Pawlic's  grip,  75. 
Pelvic  abscess,  453. 
cavity,  2. 

cellulitis    following    puerperal    in- 
fection, 452. 
fascia,  5. 

floor  seen  from  above.  111. 
anatomy  of,  5,  111. 
changes  in,  during  labor,  66,  108. 
injuries  to,  133,  508,  514. 
grip,  75. 

joints,  relaxation  of,  during  preg- 
nancy, 3. 
peritonitis  following  puerperal  in- 
fection, 453. 
Pelvimetry,  54. 
Pelvis,  1. 

anatomy  of,  1. 

articulations  of,  3. 

axis  of,  4. 

cavity  of,  2. 

coccyx,  2. 

comparison  of,  2. 

conjugata  vera,  84,  484. 

contracted  (see  Contracted  Pelvis), 

482. 
diameters  of,  84. 


Pelvis,  double  Naegele,  481. 

dwarf,  481. 

exostosis  of,  482. 

female,  2. 

flat  non-rhachitic,  481. 

flat  rhachitic.  481. 

funnel-shaped,  481. 

generally  contracted,  481. 

inferior  strait,  3. 

inlet  of,  3. 

justo-minor,  481. 

ligaments  of,  3. 
male,  2. 

Naegele's  pelvis,  481. 

normal  conjugate,  59,  84. 

oblique  conjugate  of,  59. 

obliquely  contracted,  481. 

obstetrical  conjugate  of,  59 

of  new-born  child,  4. 

osteomalacic,  482. 

outlet  of,  3. 

planes  of,  3. 

pubis,  3. 

rhachitic,  481. 

Robert's,  481. 

sacro-iliac  synchondrosis  of,  3. 

sacrum,  2. 

sexual  differences  in,  2. 

simple  flat,  401. 

spondylolisthetic,  481. 

symphysis  pubis,  3. 

transversely  contracted,  481. 

true  conjugate,  84. 

tumors  of,  482. 
Pelzer's   method   of   inducing   labor, 

522. 
Pendulous  abdomen,  36. 
Perforation  of  uterus,  505. 
Perforator,  Simpson's,  564. 
Perinseum,  anatomy  of,  5. 

changes  in,  during  labor,  107. 

lacerations  of,  133,  513,  516. 

protection  of,  107. 

rigid,  90. 
Peritonitis,  puerperal,  444,  454. 
Pernicious  anaemia  in  pregnancy,  200. 
Pessary  in  treatment  of  retroflexed 
pregnant  uterus,  216. 


IXDEX 


58S 


Phlebitis,  femoral,  473. 
Phlebotomy  in  eclampsia,  300. 
Phlegmasia  alba  dolens,  445,  473. 
Physometra,  48. 

Pigmentation  during  pregnancy,  207. 
Placenta,  20. 

adherent,  418. 

anatomy  of,  20. 

apoplexy  of,  408. 

battledore,  403,  408. 

calcification  of,  408. 

diseases  of,  408. 

duplex,  13.5,  407. 

expression  of,  121. 

fatty  degeneration  of,  408. 

functions  of,  21. 

infarcts  of,  408. 

inflammation  of,  408. 

in  multiple  pregnancy,  188,  189. 

manual  removal  of,  419. 

marginata,  407. 

mechanism  of  separation  of,  123. 

membranacea,  408. 

mode  of  delivery  of,  123. 

mode  of  extrusion  of,  123. 

multiple,  in  single  pregnancy,  407. 

normal  situation  of,  in  utero,  20. 

retained  for  months,  370,  371. 

retention  of,  418. 

separation  of,  127. 

site,  125. 

site  of  post-partum,  125. 

situation  of,  in  utero,  20. 

souffle  in,  47. 

succenturiata,  407. 

syphilis  of,  408. 

velamentous,  405,  408. 

weight  of,  21. 
Placenta  prsevia,  341. 

induction  of  premature  labor  for, 
345. 

prognosis  of,  343. 

symptoms  of,  341. 

treatment  of,  343. 

vaginal  pack  in,  345. 

version  by  Braxton  Hicks's  method, 
345. 
Placentitis,  408. 


Planes  of  pelvis,  3. 

Pneumonia  during  pregnancy,  237. 

Podalic  version,  401. 

Polarity,  law  of,  70. 

Polyhydromnios,  228. 

Polymastia  (supernumerary  breasts), 

37. 
Porro's  C;rsarean  section,  560. 
Porter  Mathew's  forceps,  546. 
Position  of  foetus,  30. 
Post-partum  haemorrhage,  349. 

primary,  349. 

secondary,  355. 

treatment,  351. 
Posture,  in  first  stage  of  labor,  109. 

in  second  stage  of  labor,  109,  116. 
Prague  manceuvre,  182. 
Precipitate  labor,  374. 
Pregnancy,  abdominal,  321. 

abdominal  bandage  in,  61. 

abnormalities  of  pigmentation  in, 
37. 

acardia  in  multiple,  186. 

acute  infectious  diseases  in,  232. 

acute  yellow  atrophy  of  liver  in, 
37. 

albuminuria  during,  273. 

alimentary  system  in,  37. 

amaurosis  in,  274. 

amenorrhoea  during,  40. 

amnion,  diseases  of,  during,  228. 

anaemia  in,  200. 

anteflexion  of  uterus  during,  211. 

anteversion  of  uterus  during,  211. 

appendicitis  in,  242. 

areola  in,  40. 

auto-intoxication  in,  284. 

ballottement  in,  44. 

bladder,  changes  in,  38. 

blood,  changes  in,  34,  200. 

bowels  in,  38. 

breasts,  care  of,  during,  61,  221. 

broad  ligament,  321,  329. 

bronchocele  in,  240. 

carcinoma  of    cervix  during,  346, 
347. 

cardiac  lesions  in,  257. 

cephalalgia  in,  202. 


584 


INDEX 


Pregnancy,  choasma  in,  37. 

cholera  in,  237. 

chorea  in,  204. 

chronic  nephritis  in,  272. 

clothing  during,  63. 

constipation  during,  61,  197. 

cutaneous  system  in,  37. 

cystitis  in,  281. 

death  of  foetus  during,  136,  409. 

decidua  polyposa  during,  226. 

dental  caries  in,  193. 

depressed  nipples  in,  61,  158. 

derangement      of      stomach      in, 

194. 
diabetes  in,  283. 
diagnosis,  differential,  48 
diagnosis  of,  38. 

of  death  of  foetus  in,  409. 

of  multiple,  191. 

of  previous  pregnancy,  53. 
diarrhoea  during,  199. 
diastasis  of  recti  muscles  during, 

218. 
diet  during,  61. 

diffuse  thickening  of  decidua  dur- 
ing, 226. 
diseases  of  alimentary   tract  and 
liver  in,  192,  194,  197. 

of  blood  in,  200. 

of    circulatory    and    respiratory 
systems  in,  200,  202. 

of  decidua  during,  225. 

of  kidneys  and  urinary  tract  in, 
272. 

of  nervous  system  in,  202. 

of  ovum  during,  225. 

of  skin  in,  207. 
displacement  of  uterus  during,  210, 

211,  212. 
disturbances  of  vision  in,  274. 
duration  of,  51. 
dyspnoea  in,  202,  257. 
eclampsia  in,  294. 
ectopic    (see    Extra-uterine   Preg- 
nancy), 310. 
emesis  in,  194. 
enlargement  during,  30. 
enteroptosis  in.  199. 


Pregnancy,  epilepsy  in,  296. 
erysipelas  in,  235. 
estimation  of  date  of  confinement 

in,  52. 
examination,  preliminary,  during, 

62. 
exanthemata  during,  232. 
exercise  durinc,  61. 
extraperitoneal,  321,  326. 
extra-uterine,  310. 
facial  paralysis  in,  206. 
false,  50. 

foetal  heart  sounds  in,  45. 
formation    of    lower    uterine    seg- 
ment, 31,  67. 
funic  souffle  in,  48. 
gastroptosis  in,  199. 
glycosuria,  283. 
goitre  in,  240. 
gonorrhoea  in,  269. 
haemorrhages  in,  240. 
haemoptysis  during,  250. 
heart,  hypertrophy  of,  in,  258. 
Hegar's  sign  of,  42. 
hernia  of  uterus  during,  218 
herpes  gestationis  in,  208. 
hydatidiform  mole  in,  226. 
hydrsemia  in,  203. 
hydramnios  in,  228. 
hydrorrhoea    gravidarum    during, 

226. 
hyperemesis  in,  194. 
hypertrophic  elongation  of  cervix 

during,  392. 
hypertrophy  of  cervix  in,  392. 
hypertrophy    of    the     ureters    in, 

43. 
imaginary,  50. 

impetigo  herpetiformis  in,  208. 
incarceration  of  the  uterus  during, 

313. 
incomplete  retroflexion  of  uterus 

during,  217. 
incontinence  of  urine  in,  283. 
indigestion  in,  194. 
influenza  in,  238. 
in    rudimentary    horn    of    double 

uterus,  329. 


INDEX 


585 


Pregnancy,     insanity     during,    204, 

430." 
insomnia  during,  203. 
intermittent  contractions  of  uterus 

during,  47. 
interstitial,  324. 
intestines,  changes  in,  38. 
intestines,  disorders  of,  in,  197. 
irritability  of  bladder  in,  280. 
kidney  of,  272. 
lactosuria  in,  283. 
laparotomy  during,  394. 
lead  poisoning  in,  240. 
leucorrhoea  in,  218. 
malaria  in,  239. 
mammie  in,  61,  221. 
management  of,  61. 
measles  in,  236. 
menses,  cessation  of,  during,  40. 

persistence  of,  during,  40. 
mental  and  emotional  changes  in, 

203. 
mental  derangements  in,  203. 
mercurial  poisoning  in,  240. 
morning  sickness  in,  40. 
movement  of  foetus  during,  45. 
multiple,  185. 
myofibromata  with,  222. 
nausea  and  vomiting  during,  194. 
nephritis  in,  272,  273. 
nervous  irritability  in,  202. 
neuralgia  in,  202. 
cedema  in,  287. 
osseous  system  in,  37. 
ovarian  cyst  complicating,  394. 
palpation  during,  73. 
paraglobulin  in  urine  of,  286. 
paralysis  in,  206. 
paraplegia  in,  206. 
pathology  of,  192. 
patient's  outfit  in,  63. 
pelvimetry  during,  .54. 
pendulous  abdomen  in,  36,  212. 
pernicious  anaemia  in,  200. 

vomiting  of,  194. 
physiology  of,  30. 
phthisis  in,  249. 
pigmentation  in,  37,  207. 


Pregnancy,  placental  souffle  in,  47. 
placentitis  in,  408. 
pneumonia  in,  237. 
preliminary-  examination  during,  62. 
prolapse  of  uterus  during,  210. 
prolonged,  52. 
pruritus  in,  207. 
pruritus  vulvae  in,  220. 
psychoses  during,  203. 
ptyalism  in,  192. 
purpura  ha>morrhagica  in,  208. 
quickening  in,  45. 
renal     insufficiency    during,    272, 

286. 
respiration  in,  36,  202. 
retention  of  urine  in,  283. 
retroflexion  of  uterus  during,  212. 
retroversion  of  uterus  during,  212. 
sacculation  of  uterus  in,  217. 
salivation  in,  192. 
scarlet  fever  in,  234. 
serum-albumin  in  urine  of,  286. 
signs  of,  .39. 
signs  of  previous,  53. 
size  of  uterus  in,  44. 
smallpox  in,  2,36. 
souffle,  funic  or  umbilical,  in,  48. 
souffle,  uterine,  in,  47. 
spurious,  50. 
striae  of,  36,  37. 
suppression  of  menses  in,  40. 
symptoms  of,  39. 
syphilis  in,  265. 
tetanus  in,  238. 
tetany  in,  238. 
thyreoid  in,  240. 
tobacco  poisoning  in,  241. 
toothache  in,  193. 
torsion  of  cord  in,  408. 
toxsemia  of,  283. 
toxsemic  kidney,  272. 
tubal,  313. 
tuberculosis  in,  249. 
tubo-abdominal,  321. 
tubo-uterine,  324. 
tumors  complicating,  49,  51,  394. 
typhoid  fever  in,  232. 
umbilicus  in,  87. 


586 


INDEX 


Pregnancy,  urea,  amount  of,  during^ 
286. 
ureters,  hypertrophy  during,  43. 
urinary  disturbances  during,  37. 
urine,     examination     of,     during, 

62. 
urine  in,  37. 
uterine   intermittent   contractions, 

47. 
uterine  displacements  in,  212. 

souffle  in,  47. 
uterus  in,  41. 
vagina  in,  43. 
vaginitis  during,  218,  269. 
valvular  lesions  of  heart  in,  258. 
varicose  veins  in,  201. 
vesicular  mole  in,  226. 
Premature  infant,  care  of,  166. 
Premature  labor,  induction  of,  520. 
Preparation  for  labor,  90. 
Presentation,  30. 

anterior  parietal,  483. 
breech,  175. 
brow,  175. 
cephaUc,  77. 
complex,  401. 
face,  169. 
footling,  176. 
head,  77. 
knee,  176. 
pelvic,  175. 
shoulder,  399. 
transverse,  399. 
vertex,  77. 
Presenting  part,  30. 
Probable  signs  of  pregnancy,  39. 
Prolapse  of  pregnant  uterus,  210 

of  umbilical  cord,  402. 
Prolonged  labor,  374. 

pregnancy,  52. 
Prophylactic  douche,  155. 
Pruritus  during  pregnancy,  207. 

vulvaj,  220. 
Pseudocyesis,  50. 
Pubes,  1 
Pudendum,  1. 
Puerperal  infection,  435. 
acute,  454. 


Puerperal  infection,  antistreptococcic 
serum  in,  462. 
auto-infection,  442. 
bacteriological  examination  of  lo- 
chia in,  456. 
bacteriology,  438. 
curettage  in,  460. 
diagnosis  of,  445. 
etiology,  436. 
hysterectomy  for,  464. 
intra-uterine  douche  in,  457. 
operative  treatment  of,  459. 
pathological  anatomy  of,  443. 
phlegmasia  alba  dolens,  473. 
pysemia  in,  442,  445,  467. 
saprsemia,  441,  452. 
septictemia,  441. 
symptoms  of,  445,  449. 
treatment  of,  474. 
ulcer,  460. 
Puerperium,  146. 
after-pains  in,  149. 
anteflexion  of  uterus  during,   148. 
binder  in,  133,  425. 
bladder  distended,  151. 
bladder  empty,  150. 
breast  binder,  156. 
breasts,  152,  425. 
care  of  patients  during,  153. 
catheterization  during,  159. 
cervix  during,  152. 
chart,  147. 
chill,  149. 
diet  during,  159. 
douching  during,  155. 
embolism  in,  475. 
establishment  of  the  secretion  of 

milk  during,  152. 
hsematoma  during,  396. 
incontinence  of  urine  during  (over- 
flow), 151. 
infection  during,  435. 
insanity  during,  430. 
involution,  147. 
laxatives  in,  160. 
leucocytosis  during,  35,  471. 
leucopenia  during,  469. 
lochia  during,  151. 


INDEX 


587 


Puerperium,  management  of,  153. 

mastitis  during,  420. 

micturition  during,  159. 

milk  fever  in,  152. 

nipples,  care  of,  during,  158,  423. 

phlegmasia  alba  dolcns  during,  445, 
473. 

retention  of  urine  during,  151. 

secretions  during,  150. 

subinvolution  of  uterus  during,  149. 

temperature  during,  150. 

urination  during,  159. 

urine  in,  150. 

vaginal  douching  during,  154. 

vulvar  toilet  during,  132. 
Prolapse  of  uterus,  210. 
Pruritus,  207,  220. 
Pulmonary  embolism,  475. 
Pulse  during  puerperium,  150. 
Purpura  ha?morrhagica  in  pregnancy, 

208. 
Pus  tubes,  479. 
Pyemia,  442,  445,  467. 

Quadruplet  pregnancy,  185. 
Quickening,  45. 
Quinine  as  an  oxytocic,  385. 
Quintuplet  pregnancy,  185. 

Rectal  enemata,  98,  500. 
Rectocele  complicating  labor,  395. 
Rectum,  carcinoma  of,  complicating 

pregnancy,  .395. 
Reduction    of    retroflexed    pregnant 

uterus,  215. 
Renal  insufRciency,  272,  286. 
Repair  of  lacerations  of  perinajum, 

513. 
Repositor    for    prolapsed    umbilical 

cord,  403. 
Respiration,  artificial,  136. 
Restitution  (External  rotation),  83. 
Retained  placenta,  418. 
Retention  of  urine,  151. 
Retinitis,  albuminuric,  274. 
Retraction     ring      (see    Contraction 

Ring),  31,  67. 


Retroflexion  of  pregnant  uterus,  212, 

217. 
Retroversion  of  pregnant  uterus,  212, 

217. 
Rheumatism  during  pregnancy,  2.39. 
Rickets,  480. 

Rigor  following  labor,  445,  450. 
Ring  of  Bandl  (see  Contraction  Ring), 

31,  67. 
Robert's  pelvis,  481. 
Room  prepared  for  labor,  92. 
Rosenmiiller,  organ  of,  12. 
Rotation,  external,  83. 

internal,  79. 
Round  ligaments  during  labor,  33. 
Rubber  gloves,  use  of,  95,  98. 
Rupture  of  uterus,  410. 

Sacculation  (Sacciform  dilatation)  of 
uterus,  217. 

Sacrum,  1. 

Salivation  in  pregnancy,  192. 

Salpingitis,  puerperal,  444. 

Salt  solution  in  eclampsia,  302. 
in  haemorrhage,  355. 

Sapr£emia,  441,  452. 

Satchel,  obstetrical,  contents  of,  95. 

Scarlet  fever  in  pregnancy,  232. 
relation  of,  to  puerperal  infection, 
235. 

Schatz's  method,  173. 

Schauta's  method,  366. 

Secundines,  retention  of,  356. 

Semmelweiss,  433. 

Septica?mia,  puerperal,  4.35. 

Serum-albumin  in  urine  of  pregnancy, 
286. 

Sex,  diagnosis  by  heart-beat,  46. 

Shock     before     and     during    labor, 
337. 

Shortening    of    cervix,    apparent,  in 
pregnancy,  32. 

Shoulder,  jaw  traction,  in  after-com- 
ing head,  181. 

Shoulder  presentation,  399. 

Shoulder,  delivery  of,  116. 

Show,  93. 

Signs  of  pregnancy,  39. 


588 


INDEX 


Simple  flat  pelvis,  481. 
Simpson,  Sir  James  Y.,  142. 
Simpson's  basilyst,  567. 

forceps,  542. 

perforator,  215. 
Skull,  depression  of,  490. 

fracture  of,  490. 
Slow  pulse  during  puerperium,   150. 
Smallpox  during  pregnancy,  236. 
Smellie's  method,  182. 
SmeUie's  scissors,  564. 
Somatopleure,  18. 
Soudan  labor  chair,  119. 
Souffle,  funic,  48. 

placental,  47. 

uterine,  47. 
Spermatozoa,  16. 
Spina  biflda,  134,  492. 
Splanchnopleure,  18. 
Spondylolisthesis,  480. 
Spontaneous  amputation  by  amniotic 
adhesions,  231. 

evolution,  400. 

version,  400. 
Spurious  pregnancy,  50. 
Stages  of  labor,  71,  98,  105,  121. 
Staphylococcus    in    puerperal    infec- 
tion, 439. 
Stenosis  of  umbilical  vessels,  409. 
Sterilizing  instruments,  498. 
Stocking-drawers,  Snively,  538. 
Stomach,  derangement  of,  194. 
Straits  of  pelvis,  2. 
Streptococcus,  439. 
Strige  of  pregnancy,  37. 
Subcutaneous  injection,  499. 
Subinvolution  of  uterus,  149. 
Succenturiate  placenta,  407. 
Sugar  in  urine,  238. 
Superfecundation,  189. 
Superfcetation,  189. 
Sutures,  499. 

for  perineal  repair,  514. 
Sylvester's  method  of  resuscitation, 

136. 
Symphyseotomy,  561. 
Syncytial  layer,  373. 
Syphilis,  265. 


Syphili  ,  during  pregnancy,  265. 
foetal,  409. 
infantfle,  493. 

Talipes,  135. 
Tampon,  505. 

in  abortion,  366,  505. 

in  accidental  haemorrhage,  338. 

in  placenta  prsevia,  345. 

in  post-partum  haemorrhage,  353. 

in  rupture  of  the  uterus,  415. 
Tamponade,  intra-uterine,  507. 

vaginal,  506,  519. 
Tarnier's  cephalotribe,  567. 

forceps,  542. 
Temperature  during  labor,  150. 

during  puerperium,  150. 
Tetanic   construction   of  uterus,   66, 

375,  378. 
Tetanus  during  pregnancy,  238. 

neonatorum,  492. 
Tetany  in  pregnancy,  238. 
Third  stage  of  labor,  71,  121. 
Thoracophagus,  405. 
Threatened  abortion,  362. 
Thrombosis  of  uterine  vessels,  445. 

of    vessels    of    lower    extremities, 
473. 
Thrush,  494. 

Thyreoid  extract  in  toxaemia  o.  preg- 
nancy, 293. 
Tobacco     poisoning     in     pregnancy, 

241. 
Tongue-tie,  494. 
Toothache  in  pregnancy,  193. 
Torsion  of  cord,  408. 

of  uterus,  87. 
Toxaemia  of  pregnancy,  283. 

symptoms  of,  285. 

treatment  of,  288. 
Transfusion  of  salt  solution,  500, 
Transverse  presentations,  399. 

cephalic  version  in,  401. 

podalic  version  in,  401. 
Triplet  pregnancy,  188. 
Tubal  abortion,  315,  319. 

mole,  315. 

pregnancy,  313. 


INDEX 


589 


Tuberculosis  during  pregnancy,  249. 

transmission  of,  to  fa-tus,  251. 
Tubes,  Fallopian,  9. 
Tumors,  complicating  pregnancy,  49, 
51. 

fibroid,  of  ut°rus,  49,  222,  394. 

osseous,  deforming  pelvis,  482. 

ovarian,  49,  394. 

phantom,   differentiation   of,  from 
pregnancy,  50. 

scalp,  489. 

vaginal,  394,  396. 
Turning    (see    Version),    345,     401, 

530. 
Twins,  185. 

locked,  403. 
Tying  the  cord,  117. 
Tympanites  uteri,  408. 
Typhoid  fever  during  pregnancy,  232. 

Ulcer,  puerperal,  460. 
Umbilical  grip,  74. 
Umbilical  cord,  23,  117,  402. 

abnormalities  of,  408. 

care  of,  135. 

coils  of,  about  neck  of  child,  113. 

development  of,  23. 

dressing  the,  135. 

formation  of,  23. 

hernia  of,  409. 

infection  of,  491. 

inflammation  of,  409. 

knots  of,  409. 

laceration  of,  398. 

ligation  of,  117. 

loops  of,  409. 

prolapse  of,  402. 

reposition  of,  403. 

rupture  of,  398. 

shortening  of,  408. 

souffle,  48. 

stenosis  of  vessels  of,  409. 

torsion  of,  408. 

tying  of,  117. 

variations  in  length  of,  23. 

varices  of,  409. 
Umbilical  ha-morrhage,  491. 
Umbilical  hernia,  491. 


Umbilical  vegetations,  491. 

Umbilicus  in  pregnancy,  87. 

Unavoidable  ha-morrhage,  341. 

Uniovular  twins,  185. 

Urachus,  20. 

Uraemia,  272. 

Urea  in  pregnancy,  286. 

Ureter,  hypertrophy  of,  43. 

Urethra,  7. 

Urinary   disturbances  in   pregnancy, 

213,  283. 
Urine,    before  or  during  labor,   108, 
110,  213. 

examination  of,  during  pregnancy, 
62. 

incontinence  of,  213,  283. 

in  toxaemia  of  pregnancy,  274. 

of  foetus,  29. 

retention    of,    during    pregnancy, 
213,  283. 
during  puerperium,  151. 
Uterus,  7. 

contractions  of,  47,  65. 

fibroids  of,  49,  222. 

inertia  of,  375. 

souffle  in,  47. 
Uterus,  non-pregnant,  7. 

ligaments  of,  11. 

lymphatics  of,  11. 

mucosa  of,  9. 

musculature  of,  8. 

nerves  of,  11. 
Uterus,  parturient,  action  of,  in  la- 
bor, 65,  67. 

anteflexion  of,  148,  211. 

atony,  375. 

faulty  contraction  of,  66,  375. 

hour-glass  contraction  of,  418. 

inertia  of,  375. 

perforation  of,  505. 

rupture  of,  410. 

sacculation  of,  217. 
Uterus,   pregnant,   abnormalities  of, 
210. 

anteflexion  of,  211. 

anteversion  of,  211. 

carcinoma  of,  346,  347. 

changes  in  cer\ax,  32,  42. 


590 


INDEX 


Uterus,  pregnant,  changes  in,  during 
contractions,  67,  70. 

changes  in  size  and  shape  of,  30. 

contractions  of,  47. 
.     developmental     abnormalities     of, 
11. 

displacements  of,  197. 

double,  11. 

incarceration  of  retrofiexed,  213. 

malformations  of,  11. 

myoma  of,  222. 

nerve  supply  of,  67. 

perforation  of,  505. 

prolapse  of,  210. 

retroflexion  of,  212. 

retroversion  of,  212. 

sacculation  of,  217. 

shape  of,  87. 

sinking  of,  31. 

torsion  of,  87. 

tumors  of,  complicating  pregnancy, 
49,  51. 

unicornis,  11. 

weight  of,  30. 
Uterus,  puerperal,  anteflexion  of,  211. 

hour-glass  contraction  of,  349,  418. 

inversion  of,  416. 

involution  of,  147. 

subinvolution  of,  149. 

weight  of,  30. 

Vagina,  7. 

atresia  of,  49. 

changes  of,  in  pregnancy,  43. 

double,  11. 

haematoma  of,  396. 

injuries  of,  during  labor,  375,  377, 
379. 

lacerations  of,  during  labor,  508, 
509. 

neoplasms  of,  394. 

prolapse  of,  in  pregnancy,  211. 

rugse  of,  439. 

secretion  of,  366,  497. 

thrombus  of,  396. 

tumors  of,  394. 

ulcer  of,  460. 
Vaginal  Ceesarean  section,  560. 


Vaginal  douche,  154,  502. 

examination,  77,  89,  386. 

secretion   in   pregnancy,  366,  439, 
497. 
in  puerperium,  440. 
Vaginitis,  puerperal,  443. 
Vagino-fixation,    cause    of   dystocia, 

393. 
Varicose  veins  in  pregnancy,  201. 
Veit-Smellie  manoeuvre,  181. 
Velamentous  insertion  of  cord,  408. 
Venesection  in  eclampsia,  300. 

in  heart  disease,  263. 
Ventro-fixation,    cause    of    dystocia, 

393. 
Veratum   viride   in    eclampsia,    301, 

309. 
Vernix,  caseosa,  26,  139. 
Version,  345,  530. 

bipolar,  345. 

cephalic,  401. 

combined,  345,  531. 

external,  531. 

internal,  533. 

in  contracted  pelves,  487. 

in    transverse   presentations,    401, 
531,  532. 

podalic,  401. 

spontaneous,  400. 
Vertebrse,  1. 
Vertex  presentations,  77. 

mechanism  of,  78. 
Vesical  calculus  complicating  labor, 

395. 
Vesicular  mole,  226. 
Vestibule,  7. 
Villi,  chorionic,  19. 

degeneration  of,  226. 
Vision,  disturbances  of,  during  preg- 
nancy, 274. 

in  eclampsia,  274. 
Vitelline  membrane,  13,  20. 
Vitellus,  13. 

Vomiting  of  pregnancy,  194. 
Vulva,  6. 

atresia  of,  49. 

haematoma  of,  396. 

injuries  of,  during  labor,  375,  396. 


INDEX 


591 


Vulva,  labia  majora,  6. 
minora,  7. 
oedema  of,  397. 
pruritus  of,  220. 

Walcher's  posture,  555,  556. 
Weight  of  foetus  at  various  months, 
23. 
of  newly  born  child,  161. 


Wet-nurse,  162. 
Wharton's  jelly,  23. 
White  line  of  Farre,  13. 
Wigand-Martin  method,  182. 
Wolffian  ducts,  12. 

Yolk,  13. 

Zona  pellucida,  13. 


(1) 


39 


A  TEXT-BOOK  OF 

GYNECOLOGY 

SECOND  EDITION 

Edited  by  CHARLES  A.  L.  REED,  A.M.,  M.D. 

Professor  of  Clynical  Gynecology  in   the    Medical    Department  of  the    University   of 

Cincinnati  (Medical  College  of  Ohio)  ;   President  of  the  American 

Medical  Association  (1900-1901). 

With  400  Illustrations  from  Original  Drawings  by  Roy  J.  Hopkins. 
8vo,  900  pages.     Sold  only  by  Subscription.     Cloth,  $5.00. 

Nearly  one-half  of  the  work  is  from  the  pen  of  the  editor,  whose  reputation  is  inter- 
national. The  rest  is  based  on  contributions  from  distinguished  British  and  American 
writers  and  teachers,  not  only  of  gynecology,  but  also  of  the  cognate  subjects  of  pathol- 
ogy, bacteriology,  neurology,  dermatology,  general  surgery,  and  internal  medicine, 
unified  and  blended  into  a  consecutive  text. 

"  Taken  all  in  all,  this  book  may  be  said  to  represent  all  that  is  accepted  by  conser- 
vative gynecologists,  and  is  a  book  which  can  be  followed  with  the  most  implicit  faith 
by  the  practitioner." — Medical  Progress,  Louisville,  Ky. 

"  Students  and  practitioners  will  find  this  text-book  a  valuable  guide  in  this  im- 
portant field  of  special  work.  The  book  is  judiciously  illustrated,  and  the  illustrations 
are  especially  well  drawn  and  hdpfu] ."  —J  ourrial  of  Medical  Science,  Portland,  Me. 

"  The  work  of  the  editor  in  properly  connecting  the  labors  of  the  different  contribu- 
tors so  that  the  book  would  not  have  the  appearance  of  a  collection  of  monographs 
has  been  stupendous.  The  successful  accomplishment  of  this  reflects  great  credit  upon 
his  judgment,  industry,  and  acumen." — IVestern  Medical  Review,  Lincoln,  Neb. 

"  There  are  thirty-one  contributors,  the  best  talent  to  be  found  in  the  United  States, 
with  the  result  that  we  have  one  of  the  very  best  works  upon  gynecology  extant.  The 
editor  is  to  be  sincerely  congratulated  on  the  outcome  of  his  labor,  but  those  who  know 
him  best  could  not  but  feel  that  such  a  book  only  could  be  produced  by  him." — New 
England  Medical  Monthly,  Danhury,  Conn. 

"  Dr.  Reed  has  placed  the  profession  under  obligations  to  himself  for  a  very  valuable 
text-book  of  gynecology.  For  clearness  of  statement,  exhaustiveness  of  treatment,  and 
fulness  of  illustration,  it  is  not  excelled  by  any  work  of  its  size.  The  author  has  suc- 
ceeded in  furnishing  a  text-book  which  will  be  a  most  valuable  working  manual  for 
practitioners  and  students,  embracing  the  best  approved  developments  of  gynecology. 
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of  North  America  and  Great  Britain.  The  editor  did  his  work  thoroughly  and  well,  and 
as  a  result  we  have  a  book  whose  contents  are  truly  refreshing,  it  is  up  to  date  in  every 
respect,  and  its  preparation  was  done  quickly  but  not  hastily.  The  different  articles 
are  well  considered,  show  much  thought  in  their  preparation,  and  give  evidence  of  large 
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as  well,  and  they  are  by  no  means  the  least  important." — St.  Louis  Medical  and 
Surgica'l  Journal. 

D.  APPLETON  AND   COMPANY,  NEW  YORK. 


CANCER  OF  THE 
UTERUS: 

Its  Pathology,  Symptomatology,   Diagnosis,  and   Treatment  ;   also 
the  Pathology  of  the  Diseases  of  the  Endometrium. 

By  THOMAS  STEPHEN   CULLEN,    M.  B. 

(Toronto),  Associate  Professor  of  Gynecology  in  the  Johns  Hopkins  University. 

Illustrated   by   MAX   BRODEL  and   HERMAN   BECKER. 

Complete   in  One    Royal   Octavo   Volume   of  about   700   pages, 
Twelve  Colored  Plates,  and  Three  Hundred  Illustrations  in  the  Text. 

Cloth,  $7.50;  half  morocco,  I8.50. 

Sold  only  by  subscription. 

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upon  the  subject.  The  book  is  of  great  value  to  the  pathologist, 
to  the  family  physician,  and  to  the  surgeon.  The  chapters  on  the 
early  recognition  of  cancer  are  so  distinct  and  clear  that  a  wayfaring 
man,  though  a  general  practitioner,  should  not  err  in  giving  or  di- 
recting prompt  and  efficient  relief." — Medical  News,  New  York. 

"A  work  of  this  class  is  an  addition  of  real  value  to  medical 
literature." — Boston  Medical  and  Surgical  Journal. 

"We  know  that  the  Baltimore  school  of  medicine  has  carried 
the  utilization  of  clinical  and  scientific  material  almost  to  perfection, 
and  this  volume  is  a  fresh  witness  to  this  truth.  Lastly,  the  clinical 
features  of  the  different  varieties  of  uterine  cancer  and  of  innocent 
disease  which  simulate  it  are  described  very  clearly  so  that  Dr. 
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ist and  the  teacher  of  pathology." — British  Medical  Journal. 

"It  represents  the  latest  exposition  of  all  that  is  known  about 
cancer  of  the  uterus,  and  we  may  say  at  once  that  as  a  monograph 
on  this  subject  it  absolutely  eclipses  any  previous  work.  No  one 
who  wishes  to  be  well  informed  on  the  subject  of  cancer  of  the 
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London. 

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